State Vital Records Office
(03/30/2015) / WISCONSIN DEPARTMENT OF HEALTH SERVICES
SVRIS ACCESS REQUEST AND CONFIDENTIALITY AGREEMENT
FOR LOCAL VITAL RECORDS OFFICES
If you need assistance, please contact the State SVRIS Application Administrator at . Fax both pages to (608) 261-4972.
SECTION I – REQUEST TYPE (to be completed by User or Local Account Administrator)
Enter DOA/Wisconsin Logon(user logon ID that user creates
at): ______
Check appropriate box(es):
New SVRIS User: Create a new account
Add SVRIS Role: Add role
SVRIS Role Change: Change role
Delete a SVRIS User: Delete account
ID Change: Change Logon ID ______
User’s Name Change: Enter user’s former name here ______ / Effective Date(MM/DD/YYYY)
N/A
Note: The State SVRIS
administrator requires one (1) week
notice prior to the effective date
listed.
Completed Required Web-based Training
Contact with questions.
SECTION II – USER INFORMATION (to be completed by User or Local Account Administrator)
Last Name
/ First Name
/ M.I / Working Title (e.g., Deputy Reg. of Deeds)
Name of Facility/Office (e.g., Dane CountyRegister of Deeds) / City
Mailing Address (Building, Room No., Street),City, Zip / Alternate Address (Building, Room No., Street), City, Zip
Work Telephone No.
( ) - ext / Email Address (example: )
SECTION III – SVRIS ROLES ASSOCIATEDWITH CUSTOMER SERVICE AND ACCOUNTING
General Addrole Delete role / Functions: search, view, use CAS, print certified and uncertified copies of certificatesfor a specific jurisdiction, and perform statewide searches.
Check with Register of Deeds to determine role.
Admin Add role Deleterole / Functions: perform all of the activities listed above, run reports, make changes to payment information within 24 hours.
Check with Register of Deeds to determine role.
Marriage Add role Deleterole / Functions: Search,view, accept & register marriage records only, scan & review scans.
Check with Register of Deeds to determine role.
SECTION IV – SUPERVISOR INFORMATION
Print Supervisor Name:
Supervisor Signature: / Supervisor Telephone No.
( ) - ext
SECTION V – LOCAL SVRIS ACCOUNT ADMINISTRATOR INFORMATION
Local SVRIS Account Administrator Name
DO NOT COMPLETE SECTION V / Local SVRIS Account Admin Telephone No. DO NOT COMPLETE SECTION V
Local SVRIS Account Administrator Signature DO NOT COMPLETE SECTION V / Date Submitted to SVRO (MM/DD/YYYY)
DO NOT COMPLETE SECTION V
Location Code
DO NOT COMPLETE SECTION V / LVRO Notes to State SVRIS Application Administrator DO NOT COMPLETE SECTION V
SECTION VI – STATE SVRIS APPLICATION ADMINISTRATOR COMPLETED BY SVRO
Processed by: / Date processed
(MM/DD/YYYY)

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DEPARTMENT OF HEALTH SERVICES

Division of Public Health
(03/24/2015) / STATE OF WISCONSIN
Chapter 69, Wis. Stats

SVRIS ACCESS RIGHTS AND SECURITY / CONFIDENTIALITY AGREEMENT

LVROs

SVRIS SECURITY / CONFIDENTIALITY AGREEMENT

Office
Register of Deeds Milw CHO West Allis CHO / County/City
Name of Employee / Job Title
Work Phone / Fax Number / Email Address

Access to Wisconsin Vital Records is governed by Chapter 69, Wis. Statutes and DHS Administrative Rule 142 (not open records law). This Security/Confidentiality Agreement shall be signed by eachSVRIS user within the above-named business entity as a condition for authorized use of SVRIS. All SVRIS users are required to accept the terms and conditions set forth in this Agreement. The employing agency agrees that, upon termination of an employee, the agency will immediately notify the State Vital Records Office by fax to (608) 261-4972 so the User Name and Password of the employee may be deactivated.

  1. Your SVRIS account is to be used only by you for official purposes related to your statutory role in the Wisconsin Vital Records program.
  2. You agree to abide by all applicable federal and state laws and policies regarding confidentiality of Wisconsin Vital Records data.
  3. You agree to respect the confidentiality and privacy of individuals whose records or data you access and to protect confidential information displayed from your workstation monitor and/or printed from SVRIS.
  4. You understand and acknowledge that SVRIS is only to be accessed by authorized users. You agree to protect the confidentiality of your Password and User Name. As an authorized user, you will not cause or permit anyone, other than yourself, to access SVRIS by use of your User Name and Password. Sharing a user account exposes the logged-in user to liability for all on-line SVRIS activities done under that user’s account. Any user found sharing his/her account with another individual may have his/her account deactivated immediately.
  5. Fax both documents as soon as possible to FAX Number (608) 261-4972.
  6. Someone from SVRO will notify you that your request for access has been approved and activated. It takes approximately one week to complete the account activation process.

Signature

I have read the above and agree to abide by its provisions. I understand that violation of the provisions stated in the Agreement may cause suspension or revocation of access to SVRIS and related privileges.

Name: (Print)______

Signature: ______Date: ______

Complete and fax both pages to (608) 261-4972

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