Dean/Vice President Name

NVSS Operator Authorization Form Send this signed & completed form to the Access Control Program - Cornell Police, 365 Pine Tree Road

Purpose: This form provides authorization by a college/unit head for Network Video Surveillance System Operators per Policy 8.1 – Responsible Use of Video Surveillance Systems. Directions: 1) Identify your unit and provide your signature granting authority. 2) Enter the name and university netID of the person to whom you are granting authority as well as a back-up to that individual. 3) Indicate, if necessary, who this person replaces. 4) Check the appropriate lines to identify the span of control and the specific authority being granted. The form must be printed, signed and sent to the Access Control Program, Cornell Police Department, 365 Pine Tree Road. College/Unit:

Dean/Vice President Name:

Signature: Date:

I grant the following individual the authority to act on my behalf as the NVSS Operator: Name: netID: If this person is replacing a current NVSS Operator, please indicate who is being replaced: Name: netID: I grant the following individual the authority to act as the back-up to the individual identified above. Name: netID:

Span of control (please indicate Facility Code(s) when indicating span of control) All departments within my unit Specific department(s): Specific facility(s): Other (specify):

Specific Authorities (within specified span of control) NVSS Operator (NVSSO) according to University Policy 8.1  Requests permission to install new, temporary, or replacement NVSS equipment; confirming with University NVSS administrator that integration into university-wide system is possible.  Ensures compliance of use of NVSS within department/unit.  Designates Associate NVSS operators.  Ensures that training and documentation (attestations) for use of NVSS is in place and compliant with Policy 8.1.  Ensures that proper signage is in place at all surveillance locations.  Designs monitoring locations to prevent tampering with recorded material.  Ensures that recorded surveillance material is in a secure location.  Conducts annual VSS audits to confirm documentation of users and access levels.

By signing this form, I agree to the requirements and responsibilities set forth in Policy 8.1 - Responsible Use of Video Surveillance Systems.

ACCC/KCC Signature: Date: ACCC/KCC Back-up Date: Title: Campus Phone: Signature: Title: Campus Phone:

NVSS Operator Authorization Form – 2/2014