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 UCLA Policy  410, Attachment  A

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UCLA Request Form for Nonconsensual Access to Electronic Communications Records

 

For more information, see UCLA Policy 410, Nonconsensual Access to Electronic Communications Records 

A.  INFORMATION SOUGHT
Name and department of Electronic Communications Record Holder:
__________________________________________________     ____________________________________________
Is the Record Holder a faculty member?  __ Yes    __ No
 
 
Attach a description of the Electronic Communications Records for which access is being requested and a detailed explanation of why nonconsensual access is deemed necessary.

B.  BASIS FOR REQUEST
Type of request (check one):
__ Prior authorization
__ Post-access authorization: Emergency Circumstances required immediate access. (Attach explanation.)
ECP provisions under which Records are to be accessed (check all that apply):
__ Required by and consistent with law
__ Reasonable belief of violation of law or UC Policy
__ Compelling Circumstances
__ Time-dependent, critical operational circumstances
 
Reason(s) why Holder’s consent cannot be obtained
(check all that apply):
__ Holder has denied a request to allow access
__ Absence, illness or death precludes requesting Holder’s consent
__ Compelling Circumstances preclude requesting the Holder’s consent
 
 

C.  REQUESTOR NAME, TITLE AND DEPARTMENT/UNIT
 
_____________________________________________________    __________________________________________
 

D.  SIGNATURE OF CAMPUS OFFICIALS
Does the Electronic Communications Holder’s department/unit head recommend access?
 
                                                     _________________________              Date:                             
Signature and Title of Electronic Communications Holder’s Department/Unit Head
__ Yes    __ No
Does Counsel or Human Resources recommend access?
 
                                                     _________________________              Date:                            
Signature of Counsel or Human Resources – check appropriate box:
 
__ Campus Counsel
__ Medical Center Counsel
__ Assoc Vice Chancellor, Campus Human Resources
__ Sr Assoc Director, Medical Center Human Resources
__ Yes    __ No
If the Holder is a faculty member, does the Academic Senate Chair recommend access?
Attach written advice provided by the Academic Senate.
__ Yes    __ No
 
 
Is Nonconsensual Access Authorized?
 
                                                     _________________________              Date:                            
Signature of UCLA Authorizing Official (see Policy 410, IV.) – check appropriate box:
 
__ Administrative Vice Chancellor
__ Vice Chancellor, Academic Personnel
__ Vice Chancellor, Student Affairs
__ Assoc Vice Chancellor/CEO Hospital System
__ Chancellor
__ Executive Vice Chancellor and Provost
 
__ Yes    __ No

E.  COMPLETED FORM ROUTING
Send a copy of this completed form, regardless of whether access is authorized, to the Chief Privacy Officer and Director, Strategic IT Policy, Office of Information Technology, 2333 Murphy, 140501 (90095-1405). Do not include attachments.
 
If access is authorized, this completed form may be presented to the appropriate technical administrator who can provide access to the records requested.  Any access authorized shall be limited to the least perusal of contents and the least action necessary to resolve the matter.

 

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