Departments can use the following template as the basis for their internal database access request forms.

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System Name:

Requestor Information:

Name:

Employee ID:

Campus Connect ID:

Phone:

Email:

Office Location:

Department:

Job Title:

Supervisor:

Supervisor email:

Access request for (data or role – note here if highly sensitive data is included in this request):

Access request level (read, modify, manage):

Business purpose for access:

Data owner (please print):

Data owner signature and date:

Supervisor signature and date:

Employee certifies that he/she agrees to maintain confidentiality of data in accordance with DePaul’s Access to and responsible Use of Data Policy and Acceptable Use Policy including protecting his/her password from unauthorized use .

Employee signature and date:​​