SQL DATABASE ACCESS REQUEST FORM by pptfiles

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									CareGroup/BIDMC
DATABASE ACCESS REQUEST FORM REQUESTOR INFORMATION **Please print clearly - All Fields are required in order to process your request quickly **
DATE: _____________________ DATE ACCESS NEEDED: Start Date: ______/______/______ End Date: _______/_______/___________
(If ongoing, leave blank)

NAME: ________________________________________________ PHONE #: (_____) ________--_________ JOB TITLE: ______________________________________ DEPT: __________________________________ BUILDING/ROOM______________________ EMAIL: __________________@BIDMC.HARVARD.EDU_ EMPLOYER:  BIDMC  Other:__________________________________________________________________

ACCESS NEEDS - Please List Server Name, Database name need access to and check permission that all apply: DB TYPE: SQL  Oracle  DB Server Name Database Name Permissions
Read  Write  Schema Change  DBO  Test/Dev  Production  Read  Write  Schema Change  DBO  Test/Dev  Production  Read  Write  Schema Change  DBO  Test/Dev  Production  Read  Write  Schema Change  DBO  Test/Dev  Production  Read  Write  Schema Change  DBO  Test/Dev  Production 

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DATABASE ACCESS REQUEST FORM Have you completed and passed the HIPAA on-line training? YES NO

YOUR DATA MANAGEMENT SKILLS - Please rate your ability to use the following tools:
APPLICATION NOT FAMILIAR BEGINNER INTERMEDIATE ADVANCED

MS Access SQL Server Other:

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APPROVAL – Must be signed by your BIDMC Director and the Application Business Owner I AUTHORIZE THE ABOVE NAMED PERSON TO HAVE ACCESS TO BIDMC DATA FOR THE PURPOSES OF PERFORMING HIS/HER JOB RELATED ACTIVITIES. IN ACCORDANCE WITH THE HIPAA SECURITY AND PRIVACY STANDARDS, THIS PERSON SHOULD BE GRANTED ACCESS TO THE MINIMUM DATA POSSIBLE IN ORDER TO SAFEGUARD THE PRIVACY OF PROTECTED HEALTH INFORMATION. BIDMC Director NAME: ____________________________________________________________________________ TITLE: _____________________________________________________________________________ SIGNATURE: ______________________________________ DATE: _________________________

Application Business Owner NAME: ____________________________________________________________________________ TITLE: _____________________________________________________________________________ SIGNATURE: ______________________________________ DATE: _________________________

FAX THIS FORM TO DBA Team: (617) 754-8025 2 of 2


								
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