UCLA

Complete this Form to obtain non-consensual access to the records specified below in accordance with the applicable requirements of the University Electronic Communications Policy and Campus Guidelines. Access which may be authorized shall be limited to the least perusal of contents and the least action necessary to resolve the matter. Attach detailed documentation as necessary. Once authorization has been obtained, the completed form may be presented to the network administrator who can provide access to the records requested.

Name of Email Holder: _________________________ Department: _____________________________

Account and System Name(s): ____________________________________________________________

Period for Which Email Records Sought  From Date: _________________ To Date: ________________

Subject of Email Records Sought: _________________________________________________________

________________________________________________________________________________________

Has access been granted due to the presence of Emergency Circumstances*?    [  ] Yes      [  ] No

If Yes, please explain:____________________________________________________________________

_______________________________________________________________________________________
*Where time is of the essence and there is a high probability that delaying action would almost certainly result in Compelling Circumstances.

Reasons why consent cannot be obtained (check all that apply):

[  ] The Email Holder has denied a request to access the specified University Records

[  ] The Email Holder cannot be contacted because of absence, illness or death

[  ] Compelling Circumstances preclude requesting the Email Holder's consent

Comments: ____________________________________________________________________________

_______________________________________________________________________________________

Provisions of the UC Electronic Communications Policy Under which Email Records are Sought (check all that apply):
University Policy states that the University shall only permit the inspection, monitoring, or disclosure of Electronic Mail without the consent of the holder under one or more of the following circumstances.

[  ] Required by and consistent with law      [  ] Violation of law or UC Policy

[  ] Compelling Circumstances      [  ] Time-dependent, critical operational need

Requested by: ______________________________________________ Date: ________________

Requestor's Department/Unit: _______________________________________________________

Signatures of Campus Officials:

Is Non-Consensual Access recommended?    [  ] Yes      [  ] No

_____________________________ ___________________________ Date: ____________________
Signature and Title of Email Holder's Department/Unit Head

Is Non-Consensual Access recommended?    [  ] Yes      [  ] No

___________________________________________________ Date: ____________________
Signature of one of the following (check the appropriate box):

[  ] Campus Counsel       [  ] Medical Center Counsel       [  ] AsstVC - CHR       [  ] Sr Assoc Dir - Med Ctr HR

Is Non-Consensual Access approved?    [  ] Yes      [  ] No

___________________________________________________Date: ____________________
Signature of one of the following (check the appropriate box):

[  ] Vice Chancellor - Academic Personnel   [  ] Vice Chancellor - Student Affairs   [  ] Administrative Vice Chancellor

[  ] Assoc VC/CEO - Hospital Systems   [  ] Exec Vice Chancellor/Provost   [  ] Chancellor

Campus Officials should retain a copy of the completed form and send the original to the Director, IT Policy, OIT.    

Rev. 7/2007