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pWiHK59RsS2agZXGVtBMUtpsPDPkNRRUwvpwNmgkkKayGw2oBXqhrApV2Ncp4quAMRMF64wnqak6N4YazLS6TUp9WBJGxZLg5zw5HGBpwBHTUcp8GqggvUCmGsEX4

Departing Personnel Form

Returning?

A A A

Please complete the Departing Personnel Form below.

Thank you!

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Departing Personnel Data Management and Access Form

The Departing Personnel Data Management and Access Policy specifies the appropriate disposition of Stanford High Risk Data in the possession of any departing member of the Stanford Community.

This form serves as an attestation for departing personnel who will not require continuing access to any Stanford data and as a request form for those who wish to request continuing access.

You should review the Departing Personnel Data Management and Access Policy prior to completing this form. It is important for you to provide as much information as possible to support your request for continuing access to Stanford Data.

Departing personnel are not authorized to access High Risk Data after leaving Stanford without approval from the Data Governance Board.

Questions about the form should be directed to the University Privacy Office at privacy@stanford.edu.

Attachment:Departing Personnel Policy FINAL -- 20160715.pdf

Are you completing this form on behalf of someone else?

Yes

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SUNet ID of person completing the form on behalf of departing individual

* must provide value

SUNet ID of Departing Person

* must provide value

Name of Departing Person

* must provide value

Phone

* must provide value

Departer affiliation

Primary department

* must provide value

Departer Org ID

School or Administrative Unit

* must provide value

Specify other Administrative Unit

Last day at Stanford?

* must provide value

M-D-Y

New Institution, if applicable

Supervisor/manager/department chair email

* must provide value

I will require continued access to the following Data Type(s) or servers, databases, or applications containing the following Data Type(s):

Data Risk Classifications

* must provide value

High Risk Data (approval required)

Moderate Risk Data

Low Risk Data

None

Are you listed on any active IRB protocols where you have not completely transitioned off?

* must provide value

Yes

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List all active IRB protocol numbers where you have not completely transitioned off.

I, ______, have read and understood the Policy titled, "Departing Personnel Data Management and Access," and, if I handle Hospital data, I have read and understood the Hospital's departing personnel policy.

* must provide value

Yes

I, ______, certify that, if I had any of the following, I have worked with my manager and my department's IT resources to return or relinquish:

ORIGINALS of all Stanford Data, as defined by RPH 1.9, and any means to access such Data

Administrative access to all Stanford Data and systems, including research Data

Stanford-owned computing devices (laptops, desktops, tablets, phones, and other devices)

Stanford-owned storage devices (hard drives, flash drives, or other media)

Notebooks, including lab notebooks, employee charts, and meeting notes

Database/registry passcodes

Keys and access cards

All other Stanford assets

Yes, I certify to all of the above.

No, I don't certify.

I never had access to any of these.

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I, ______, have worked with my manager and my department's IT resources to relinquish access to all Stanford systems, servers, and applications (e.g., Epic, STRIDE, Medicine Box, Cerner, Oracle E-Business Suite, SeRA) and agree not to access or use any systems, servers or applications without explicit written permission.

* must provide value

Yes No

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I, ______, have removed all contractually-bound or Stanford High Risk Data from my personal devices, including laptops, desktops, tablets, phones, and external storage devices.

* must provide value

Yes No

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I, ______, certify that any retained data is fully de-identified and that I will not attempt to re-identify the data.

* must provide value

Yes No

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I, ______, agree not to access or use any contractually-obligated or Stanford High Risk Data after departure, even if access privileges have not been revoked.

* must provide value

Yes No

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I request continued access to the following type(s) of information (select all that apply and provide justification for need to access post-separation below):

* must provide value

Data related to human subjects, including human stem cells

Protected Health Information (PHI)

Personally identifiable information (PII)

Student education records

Technical Data subject to export controls or International Traffic in Arms Regulations (ITAR)

ORIGINAL records of research, as defined in RPH 1.9

Genomic Data

Data related to a patent or other intellectual property filing

Data owned by a third party and contractually-bound

U.S., Government Data

Data combined with third party information subject to any restrictions

Data subject to any special security requirements

High Risk Data requested for use outside of the United States

Other High Risk Data (describe in comments below)

I am requesting human subjects data under the following IRB protocols:

The Stanford Data that I will be accessing/handling will be physically located in or housed in a server located in:

* must provide value

The United States

Another country

Specify country(ies) where Stanford Data will be physically housed.

* must provide value

I will be accessing Stanford Data from:

The United States

Another country(ies)

Specify country(ies) from which you will access Stanford Data.

* must provide value

Please provide any other relevant information related to continued access to Stanford Data.

Expand

I, ______, acknowledge the following:

I certify that any request meets the Minimum Necessary standard.

I acknowledge and accept a duty to immediately report to the Stanford Privacy Office any breach or suspected breach of the Data for which use or access is approved.

I agree to accept full responsibility and stewardship for the Data and to comply with all Stanford policies concerning individuals' privacy, information security, HIPAA, and any other relevant Stanford policies.

I agree to only use and disclose the Data as approved by the IRB, or as permitted by my contract, if no IRB review is required.

I agree to comply with any security or risk mitigation plan that has been approved as part of my request.

Excluding the Data specifically approved for continued access above, I have worked with my IT resources to relinquish access to all other Stanford systems, servers, and applications (e.g. Epic, STRIDE, Medicine Box, Cerner, Oracle E-Business Suite, SeRA) and agree not to access or use any systems, servers or applications without explicit permission.

Excluding the Data specifically approved for continued access above, I have removed all other Contractually-bound or Stanford High Risk Data from my personal devices, including computers, tablets, phones, and external storage devices.

Excluding the Data specifically approved for continued access above, I agree not to access or use any Contractually-bound or Stanford High Risk Data after departure, even if access privileges have not been revoked.

* must provide value

Yes, I certify to all of the above.

No, I don't certify.

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Notes from Data Request Approval review: ______

Notes from Human Subject Approval review: ______

Notes from PHI review: ______

Notes from PII review: ______

Notes from Student Education Record review: ______

Notes from Technical Data review: ______

Notes from original records of research review: ______

Revision 1 complete

Revision 2 complete

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Review of revision #1 complete

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