Securid Token Action Request - Request a New Securid Token

Request a SecurID Token Token #: ______

Expiration Date: ______

First Name: ______MI: ______Last Name: ______

Department: ______Title: ______

RACF-ID: ______SSN: ______Phone/Beeper: ______

VUMC Address: ______Email Address: ______

The SecurID Token is an authentication device, the use of which is subject to the terms and conditions described in the VUMC Confidentiality Agreement and the VUMC Security Guidelines on Remote Access. You are expressly prohibited from using this device without having an active VUMC Confidentiality Agreement on file in your department. There is a $75.00 charge for obtaining a SecurID Token. These tokens have a three-year life span and will cease to present an authentication code at that time. Actual life span may vary depending on when you receive your token. The exact expiration date can be found on the back of the token under the serial number. Once your token has expired, you will be required to purchase a new token.

My signature below indicates that I have read, accept, and agree to abide by VUMC’s “Security Guidelines on Remote Access”. These guidelines can be found at: https://www.mc.vanderbilt.edu/security/RemoteAccess.doc

Signature of SecurID Token User: ______Date: ______

This request must be authorized by the Director (or higher level position) of the individual requesting the token. In accordance with VUMC’s Authorization Policy “director” is defined for these purposes as the following:

For Faculty: Department chair and/or Division Chief For Housestaff: Associate Dean for GME For Staff: Department Director or Hospital Administrator For Students: Associate Dean of Undergraduate Medical or Nursing Education

Security Manager’s Printed Name: ______VUNet-ID______

Security Manager’s Signature: ______RACF-ID______

My signature below indicates that this individual requires remote access to StarChart/StarPanel in order to fulfill their job responsibilities.

Director’s Signature: ______Date: ______Please submit this form via fax to 322-9075 or by mail to:

Systems Access and Maintenance Informatics Center Operations 3401 West End, Suite 500E (8363)

Requests will generally be processed within 72 hours. Tokens must be picked up at the VUMC Help Desk located in the basement of VUH. Please bring a signed 1180 (requisition form) when picking up your token.

Last Revised: June 22, 2005