UCLA

A.  REQUESTOR NAME, TITLE AND DEPARTMENT/UNIT

__________________________________________     ____________________________________

B.  Basis for Exception Request

Attach a detailed explanation of the circumstances for which an exception is deemed necessary. Include proposed controls in place of encryption to be used to protect electronically stored Personal Information. Consult with the Organization’s IT Compliance Coordinator for assistance.

C.  SIGNATURE OF CAMPUS OFFICIALS

Does the Requestor’s Organization Head recommend approval?

                                                                                                   Date:                              

Signature and Title of Organization Head

o Yes    o No

Does the Information Security Officer recommend approval?

_______________________________________________      Date:                             

Signature of Information Security Officer – check appropriate box:

o Yes    o No

o Campus

o Health System and School of Medicine

Does the Privacy Officer recommend approval?

_______________________________________________        Date:                             

Signature of Privacy Officer – check appropriate box:

o Yes    o No

o Campus

o Health System and School of Medicine

Is the requested exception to encryption of electronically stored Personal Information authorized?

______________________________________________          Date:                             

Signature of UCLA Authorizing Official (see Policy 404, IV.) – check appropriate box:

o Yes    o No

o Administrative Vice Chancellor

o Vice Chancellor, Health Sciences/Dean, School of Medicine

o Chancellor

o Executive Vice Chancellor and Provost

D.  COMPLETED FORM ROUTING

The completed form should be returned to the Requestor named above.

A copy of the completed form must be sent to the Chief Information Security Officer, IT Services, 3327 Murphy Hall, 143401 (90095-1434). Do not include attachments from Section B with this copy.