Network Access Request

First Name *

Phone Number *

Vendor Name *

What is the primary service that this vendor will be providing? *

What data elements (fields) will be shared, collected, processed or managed by the vendor or in performing the services noted above?

Have compliance officials been included in the process (check all that apply)?

HIPAA
IT Enterprise Security for Firewalls, network connectivity, custom Firewall,VLAN segregation, etc.?
PCI - Merchant Services
Not applicable

Acknowledgement: I declare that all the information I have provided on this formis true and accurate to the best of my knowledge. I understand that misrepresentations or incorrect information provided to IT Health Technologies can result in suspension or revocation of my credentials. *

Last Name *

Email *

Website / URL

Do the data elements fall under the definition of "sensitive data" and protection by University policy and or regulatory requirements (HIPAA, FERPA, HB5, PCI, Export Control, Research, etc)? See definition of Sensitive Data linked below.

Has the vendor discussed or mentioned that subcontractors or other service providers will be involved in the process? Example: Any cloud based data storage. If other contractors will be involved please explain here. (Example: AWS)

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