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User Exit Form

VIEWS: 13 PAGES: 4

									                 User Exit Form for IT Resources
         Division of Information Technology & Medical Informatics
         Marshall University Joan C. Edwards School of Medicine
                      University Physicians & Surgeons
                               Revised: 2/18/04

Complete this form and submit it to the Division of Information Technology when
a workforce member in the School of Medicine/UP&S departs the institution.

                     Today’s Date:

           User’s Departure Date:

                User’s Full Name:

                       User’s Title:

    User’s Employee / Student ID:

       User’s Network Username:
                        (if known)
                     Department:
                   (if applicable)
                      User’s Role: □ Resident Physician
                      (check one) □ Medical Student Class of ___________
                                    □ Medical Sciences MS Student
                                    □ Forensic Science MS Student
                                    □ Biomedical Sciences MS/PhD Student
                                    □ Clinical Faculty, Staff or Administrator
                                    □ Other Faculty, Staff or Administrator
 User had access to the following □ Banner (notify UCS)
             special applications: □ Affinity (notify CHH IT)
             (check all that apply) □ Physician’s Access (notify CHH IT)
                                    □ SMS (notify St. Mary’s IT)
                                    □ VA Med Rec / Order Entry (notify VA IT)
                                    □ OTG Medical Records
                                    □ Macola
                                    □ IDX
                                    □ Other __________________________
         User’s postal forwarding
                          address:
     (include street address, city,
                    state and ZIP)


    Person completing this form:
                    (your name)
Log of actions taken for this account:

For Student Accounts (medical, medical sciences, forensics & BMS)
                                                         Date    Completed
Action Taken                                           Completed    By
MUSOM Network login disabled.

Contents of V: drive exported to CD-ROM drive,
sent to student and emptied from medix server (but
directory retained). Copy retained by IT
department.
File \\medix\ditmi\where-are-my-files.txt copied to
user’s directory on medix.
Email address removed from Outlook/Exchange
contact list.
Email address removed from appropriate email
distribution list (unless student is medical student
and has graduated).
Permissions from applicable “special applications”
(indicated above) removed and external IT entities
(UCS & CHH) notified where appropriate.
Explanatory notice sent to student via postal
address indicated above.

For Resident Physician Accounts
                                                         Date    Completed
Action Taken                                           Completed    By
MUSOM Network login disabled.

Contents of V: drive exported to CD-ROM drive,
sent to resident and emptied from medix server
(but directory retained). Copy retained by IT
department.
File \\medix\ditmi\where-are-my-files.txt copied to
user’s directory on medix.
Email address removed from Outlook/Exchange
contact list (if applicable).
Permissions from applicable “special applications”
(indicated above) removed and external IT entities
(UCS & CHH) notified where appropriate.
Explanatory notice sent to resident via postal
address indicated above.
For Faculty, Staff or Administrator Accounts
                                                        Date    Completed
Action Taken                                          Completed    By
MUSOM Network login disabled.

Review by user’s supervisor of personal computer
and network files and contents of Exchange email
account. Appropriate transfer or disposal of any
PHI or other information resources completed
(details in “Special Actions Taken,” below).
MUST be completed prior to contents of V: drive
and Exchange email account being exported to
CD-ROM.

Supervisor Sig.:___________________________
Contents of V: drive exported to CD-ROM drive,
sent to user and emptied from medix server (but
directory retained). Copy retained by IT
department.
File \\medix\ditmi\where-are-my-files.txt copied to
user’s directory on medix.
Contents of Exchange email account ex-merged to
.PST file and included on CD-ROM with contents of
V: drive. Copy retained by IT department.
Exchange email account deleted.

Email delivery location updated on MUNet email
gateway and set not to forward incoming email to
SOMEXCHANGE.
Permissions from applicable “special applications”
(indicated above) removed and external IT entities
(UCS & CHH) notified where appropriate.
Explanatory notice sent to user via postal address
indicated above.
Immediate supervisor review of personal computer
and network files and appropriate transfer or
disposal of any PHI or other information resources
completed (MUST be completed prior to contents
of V: drive being exported to CD-ROM).
Special Actions Taken
Action Taken
File- or application-specific passwords,     Date      Completed
cryptographic keys recovered, etc.         Completed      By




Attach additional sheets if necessary.

								
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