Last Name:

Empl ID:

Full time Part time

Business Unit / Campus:

Work Phone: Ext:

Date:

Confidentiality Agreement Code:

Business Unit / Campus:

Phone:

Date:

Managerial Approval (Requesting Supervisor):

In the absence of written signature: Please email your approval to the appropriate campus party, per your campus' request process.

Action Requested (Check Only One):

Dept / Office:

JobTitle:

In the absence of written signature: Employees may accept the Confidentiality Statement in CUNYfirst via Employee Self Service. Go to: http://home.cunyfirst.cuny.edu, log in and navigate to, Human Capital Management > Self Service > CF Confidentiality Statement

Vaccination Verification User Access Request Form

EMPLOYEE INFORMATION SECTION (Please Print) :

Job Title:

CONFIDENTIALITY STATEMENT (must be signed by the Employee) :

Dept / Office:

CUNY Email Address:

Please note: This form is required in order to request access to the CUNYfirst system. This form must be approved by the employee’s supervisor. Employees may NOT approve or grant access for themselves. For transferring employees, a separate form must be completed from the Campus and/or Department transferring FROM and TO in order to access in both areas. This request must be made in advance of the effective date of the personnel action.

CUNY Email Address:

Managerial Signature:

Employee's Signature:

First Name: MI:

I understand that the data obtained from any CUNYfirst system is considered confidential and NOT to be shared with anyone who is not authorized to receive such data. I understand that I am individually accountable for the use of my User ID in the CUNYfirst system. Improper use of my User ID could lead to revocation of access rights and further disciplinary proceedings in accordance with CUNY policies, rules and regulations, and applicable collective bargaining agreements.

Add Access Remove Access Delete All Access

If you are a student, please specify college:

Last Name: First Name:

VaccVerf v1.0 08/20/2021

Last Name: First Name:

Signature: Date:

Last Name: First Name:

Signature: Date:

In the absence of written signature: BPO may email approval to the appropriate campus party, per your campus' request process.

Student Records Approval

Empl ID: _________________ Last Name: _____________________________________ First Name: ________________________________________

* Note for ASLs - Approved HR Role to be assigned in the Campus Solutions pillar.

CU_CSSR_Vaccination_Verf_Admin

CU_CSHR_Vaccination_Verf_Admin

Allows campus 'Local Vaccination Authority (LVA)' to administer the SARS Vaccination related information provided by the students. Requires Academic Institution SACR.

Allows authorized campus HR Office Personnel to administer the SARS Vaccination related information provided by employees.

CU_CSSR_Vaccination_Verf_Rpts

Academic Institution - Specify Academic Institution employee is allowed to access.

Data Permissions (SACR) Security - Secure Student Administration

CAMPUS SOLUTIONS (Roles Require Student Records Owner Approval)

HR Director Approval

Provides access to report(s) for vaccination SARS data.

HUMAN RESOURCES (Role Requires HR Director Approval)

VaccVerf v1.0 08/20/2021