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SYSTEMACCESS/ CHANGE APPLICATION
Instructions on Page 4
TYPEOFREQUEST
INITIAL MODIFICATION RECERTIFICATION DEACTIVATION / DATE(YYYYMMDD)
SYSTEMNAME(Please provide a separate application for each system.)
PPS Decision Support PPS Data Warehouse
PARTI(TobecompletedbyRequestor)
1. NAME(Last, First,Middle Initial) / 2.EMPLOYEE ID
3.HOME DEPARTMENT NAME & CODE
4.EMAIL ADDRESS / 5.TELEPHONE
6.JOB / WORKING TITLE / 7.CAMPUS UCD LOGIN (Kerberos ID)
8.TYPEOFACCOUNT ACCESSREQUIRED:(FOR: PPS Data Warehouse use only)
INDIVIDUAL(ANALYSIS) DEPARTMENT (SYSTEM)
9.JUSTIFICATIONFORACCESS(Please be specific in describing access need and how data will be used. For system account access, include computer/system and IP. You may be contacted by a member of the authorization team for clarification.)
Access to the Payroll/Personnel System Data Warehouse or Decision Support is granted for the performance of your assigned duties ONLY. Misuse or abuse of computer access privileges are serious matters which may constitute violations of the federal and/or state criminal statues, as well as violations of the California Information Practices Act and the Family Rights and Privacy Act of 1974. Employees with access to personal and confidential records shall take all necessary precautions to assure proper safeguards are established and followed to prevent unauthorized access and to protect the confidentiality of employee records. Employees may not disclose personal or confidential information concerning individuals to unauthorized persons or entities as specified by Personnel Policies, other Campus Policies and Collective Bargaining Agreements. Violations of relevant policies and law could result in penalties such as suspension, termination, fines, imprisonment, or other criminal penalties for acts, which constitute crimes. See the following UCD and UC policies set forth in the UC Policies Applying to Campus Activities, Organizations, and Students (1994): UC Davis Policy and Procedure Manual Section 320-20 Privacy of and Access to Information, Section 320-21 Disclosure of Information from Student Records,Section 380-17 Improper Governmental Activities,Section 310-22 UC Davis Cyber-safety Program, and Section 310-75 Whole Disk Encryption
10.USERSIGNATURE / 11. DATE(YYYYMMDD)
PARTII–INFORMATION ACCESS
12.INFORMATION REQUESTED (Identify information including divisions, departments, reports, tables, and fields as needed.)
13.TYPEOF DATA ACCESSREQUIRED
Non-Personally Identifiable Information Only Personally Identifiable Information (PII)
14. PII (List all requested PII data elements)
PARTIII–INFORMATION SECURITY (Required for PII access. Attach additional pages as necessary to provide required information.)
15.UC CYBER SECURITY AWARENESS TRAINING (Attach copy of certification.)
IhavecompletedAnnualInformationAwarenessTraining.DATE(YYYYMMDD):
16. If there are any other UCD personnel who will have access to data, please list names, UCD login IDs, and email addresses.
17. If there are any other non-UCD personnel who will have access to data, please list names, UCD login IDs, and email addresses.
18. Is there a federal, state, or Office of the President mandate requiring the use of PII? If yes, please describe.
19. If PII will be transmitted, describe the transmittal process. Will data be encrypted in transit?
20. If PII will be stored, describe why it must be stored. Will data be encrypted at rest?
21. Will the data be stored in a cloud, either via cloud file storage, cloud server hosting, or third-party application? If yes, describe service and security implementation. Please provide relevant documentation such as acceptance of UC Data Security terms.
22. Are you making the data available through a web application, reports, API, web service, or other secondary distribution mechanism? If yes, please describe your audience and how you will protect PII. Does your server environment comply with UCD Cyber-Safety Policy?
PARTIV–TECHNICAL SUPPORT CONTACT (Requestor’s department contact for coordinating resolution of any hardware/software issues.)
23. NAME(Last, First,Middle Initial) / 24.TELEPHONE
25.EMAIL ADDRESS
PARTV-ENDORSEMENTOFACCESSBYUSERSUPERVISORORSPONSOR
By signing this form, I accept responsibility for the permission/change to access the Payroll/Personnel System Data Warehouse or Decision Support for the individual identified above, and acknowledge that I am responsible for ensuring that such access is not misused. I also understand that it is my responsibility to take appropriate action to remove this person’s access if the individual’s responsibilities change, such that access to PPS Data Warehouse or Decision Support is no longer required for successful completion of duties of the position. NOTE: I ensure that our request for access to data outside of our department / division was approved by an authorized person from that school, division, unit, or department. (Please attach authorization.)
26.VERIFICATIONOFNEEDTOKNOW
Icertifythatthisuserrequiresaccessasrequested. / 27.ACCESSEXPIRATIONDATE
28.HOME DEPARTMENT NAME & CODE / 29.E-MAILADDRESS
30.TITLE / 31.TELEPHONE
32.AUTHORIZING AUTHORITY (Last, First,Middle Initial) / 33.AUTHORIZING AUTHORITY SIGNATURE / 34.DATE(YYYYMMDD)
PARTVI-ENDORSEMENTOFPPS OFFICER/COORDINATOR (See footnote)
35.SIGNATUREOFPPS OFFICER/COORDINATOR / 36.TELEPHONE / 37.DATE(YYYYMMDD)

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * *INTERNAL USE ONLY* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

USERID

Access:

UNIVERSAL ACCESS / FUNCTIONAL UNIT(S) / DEPARTMENT(S) / ADDITIONAL RESTRICTIONS
ACCESS APPROVED/GRANTED /
DATE

The following are instructions in completing this System Access/Change Application.

This document is a MS Word document. Please complete ENTIREdocument by typing in your information.

TYPE OF REQUEST:Self Explanatory.

DATE:Self Explanatory.

SYSTEM NAME:Self Explanatory. Please complete application for each system you are requesting.

PART I: To be complete by the Requester.

  1. NAME: Self Explanatory.
  2. EMPLOYEE ID: Self Explanatory.
  3. HOME DEPARTMENT NAME & CODE: Per PPS.
  4. EMAIL ADDRESS: Per UCD Directory
  5. TELEPHONE: Your work phone or your work cell phone; Per UCD Directory.
  6. JOB / WORKING TITLE: Per PPS.
  7. CAMPUS UCD LOGIN (Kerberos) ID: Self Explanatory
  8. TYPE OF ACCOUNT ACCESS REQUIRED: (Use for Data Warehouse access only)
  9. INDIVIDUAL (ANALYSIS): (This access allows the individual to analysis and/or dev/test program/application for the department’s needs.)NOTE: This access terminates when the individual separates from the department.
  10. DEPARTMENTAL (SYSTEM): (This access allows the department’s system to generating outputs for the department.)NOTE: This access will have a revolving owner so it does not disrupt work stoppage.
  11. JUSTIFICATION FOR ACCESS: Self-Explanatory. If the requester is a Temporary Employee/Student, please provide the end date of their assignment.Please be specific in the justification.
  12. USER SIGNATURE: the requester’s signature
  13. DATE: Self-Explanatory.

PART II: INFORMATION ACCESS.

  1. INFORMATION REQUESTED:

FOR PPSDW: Identify what data you are seeking to extract. Include as much information as you can, preferably tables, views, and fields as necessary. Please identify the department(s) or school(s)/division(s) you need access to. Also, provide the IP Address of the system that will be used.

FOR PPS DS: Identify the department(s) or school(s)/division(s) you need access to, also specific report(s).

  1. TYPE OF DATA ACCESS REQUIRED:See
  2. PII: See UCD PPM Section 320-20.Self-Explanatory.

PART III: INFORMATION SECURITY.

  1. UC CYBER SECURITY AWARENESS TRAINING:Self Explanatory.

16-22. Please answer all questions.Self-Explanatory.

PART IV: TECHNICAL SUPPORT CONTACT.

23-25. Please provide your department Technical Support Contact information. Your IT team name, email address, and phone as appropriate.Self-Explanatory.

PART V: ENDORSEMENT OF ACCESS BY USER SUPERVISOR OR SPONSOR:

26-34. This section should be completed by the Supervisor or Sponsor and their signature,NOT the PPS Officer/Coordinator.Self-Explanatory.NOTE: (27) Appointment End Date or “INDEF” for career staff/acad.

Submit completed application to your PPS Officer/Coordinator for their signature

PART VI: ENDORSEMENT OF PPS OFFICER/COORDINATOR (See Footnote of request).

35-37. To be completed by the PPS Officer/Coordinator and their signature.Self-Explanatory.

Please return this application to: Scan and Email to: . PPS DS/DW Form, 1 August 2016

Departments: Please have your PPS Officer/Coordinator [ sign Part V before submitting request.

UCDHS Department – Send your application to: PPS Access Coordinator, General Accounting, Suite 2700, Broadway Building, UCDMC Sacramento

SOM Department – Send your application to: SOM Dean’s Office (Sherman Building), Attn: PPS Officer/Coordinator.