DEPARTMENT OF CHILDREN AND FAMILIES Division of Management Services AGENCY DATA SECURITY STAFF Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. Please Print Name Agency Name Local Agency Director – – FUNCTIONAL AGENCY SECURITY SECURITY OFFICER BACK UP SECURITY OFFICER LIAISON (FASL) Name (Last, First, MI) – Job Title Employing Agency Address Work (Street, City, State, Zip Code) – Telephone Number Work – Fax Number Work – Email Work – Work Days Work Hours I have read the client confidentiality regulations covered by state policy and federal/state statutes and understand their relationships to authorizing access to client information and will ensure such confidentiality. SIGNATURE Security Officer Date Signed – SIGNATURE Back up Security Officer Date Signed – SIGNATURE FASL Security Officer Date Signed – SIGNATURE Agency Director Date Signed – DCF-F-DWSW11652 (R. 04/2013)
DEPARTMENT OF CHILDREN AND FAMILIES Division of Management Services AGENCY DATA SECURITY STAFF Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m), Wisconsin Statutes]. Please Print Name – Agency Name – Local Agency Director SECURITY OFFICER BACK UP SECURITY OFFICER FUNCTIONAL AGENCY SECURITY LIAISON (FASL) Name – (Last, First, MI) Job Title Employing Agency Address – Work (Street, City, State, Zip Code) Telephone Number – Work Fax Number – Work Email – Work Work Days Work Hours I have read the client confidentiality regulations covered by state policy and federal/state statutes and understand their relationships to authorizing access to client information and will ensure such confidentiality. SIGNATURE – Security Officer Date Signed SIGNATURE – Back up Security Officer Date Signed SIGNATURE – FASL Security Officer Date Signed SIGNATURE – Agency Director Date Signed DCF-F-DWSW11652 (R. 04/2013)
11652.docx