MDH Form 4622 "Mdh-HQ Mobile Device Accountability Acceptance and Policy Acknowledgement" - Maryland

What Is MDH Form 4622?

This is a legal form that was released by the Maryland Department of Health - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2017;
  • The latest edition provided by the Maryland Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of MDH Form 4622 by clicking the link below or browse more documents and templates provided by the Maryland Department of Health.

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Download MDH Form 4622 "Mdh-HQ Mobile Device Accountability Acceptance and Policy Acknowledgement" - Maryland

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MDH-HQ MOBILE DEVICE ACCOUNTABILITY ACCEPTANCE
AND POLICY ACKNOWLEDGEMENT
Responsibility
As the user of MDH mobile device equipment identified below, the MDH employee signing this statement acknowledges the
responsibility to be careful with its use and to keep it secure at all times, guarding against loss or theft. All mobile device
equipment remains the property of MDH and must be returned to MDH.
Accountability
1.
MDH mobile device equipment must not be altered or changed, including but not limited to software and hardware
changes, without specific written authorization from the MDH Telecommunications Coordinator.
2.
The employee must report damaged, lost or stolen mobile device equipment to their unit manager as soon as
practical, but no later than the next business day.
3.
If MDH mobile device equipment is stolen, the employee/user must initiate a police report before the equipment can
be replaced.
4.
If equipment is apparently negligently handled and damaged, or the mobile device equipment is lost, the
Department may determine that the employee is responsible for paying the comparable equipment replacement
cost.
5.
Comparable equipment replacement cost will be based on the cost to MDH to replace the mobile device equipment
using the then current hardware standards of the Department, not to exceed the original cost of the equipment.
6.
At termination of employment, mobile device equipment must be returned to MDH in good working order or else be
considered lost or damaged, wherein the employee may be held responsible for paying the comparable equipment
replacement cost
.
Acceptance
By my signature below, I acknowledge receipt of the following MDH mobile device equipment in good working condition.
Additionally, my signature below indicates that I have read and understand the State and MDH Mobile Device and
Services Policies and agree to the conditions of these policies
.
________________________
___________________________
Administration
Printed Name Of Mobile device User
________________________
___________________________
Position/Title
Location:
___________________________
________________________________
Mobile device #:
Manufacturer Name/Model:
_______________________
___________________________
Serial # (ESN):
Vendor:
_______________________
____________________________
Inventory #:
Account #:
__________________________
____________________________
Mobile device User’s Signature
Date
Unit Telecommunication Monitor’s Name
Mobile device Return Receipt
**************************************************************************************
_________________________
________________
Telecommunications Monitor Signature
Date Equipment Returned
A SIGNED COPY OF THIS FORM SHALL BE GIVEN TO THE EMPLOYEE WHEN MOBILE DEVICE EQUIPMENT IS RETURNED
MDH-HQ MOBILE DEVICE ACCOUNTABILITY ACCEPTANCE
AND POLICY ACKNOWLEDGEMENT
Responsibility
As the user of MDH mobile device equipment identified below, the MDH employee signing this statement acknowledges the
responsibility to be careful with its use and to keep it secure at all times, guarding against loss or theft. All mobile device
equipment remains the property of MDH and must be returned to MDH.
Accountability
1.
MDH mobile device equipment must not be altered or changed, including but not limited to software and hardware
changes, without specific written authorization from the MDH Telecommunications Coordinator.
2.
The employee must report damaged, lost or stolen mobile device equipment to their unit manager as soon as
practical, but no later than the next business day.
3.
If MDH mobile device equipment is stolen, the employee/user must initiate a police report before the equipment can
be replaced.
4.
If equipment is apparently negligently handled and damaged, or the mobile device equipment is lost, the
Department may determine that the employee is responsible for paying the comparable equipment replacement
cost.
5.
Comparable equipment replacement cost will be based on the cost to MDH to replace the mobile device equipment
using the then current hardware standards of the Department, not to exceed the original cost of the equipment.
6.
At termination of employment, mobile device equipment must be returned to MDH in good working order or else be
considered lost or damaged, wherein the employee may be held responsible for paying the comparable equipment
replacement cost
.
Acceptance
By my signature below, I acknowledge receipt of the following MDH mobile device equipment in good working condition.
Additionally, my signature below indicates that I have read and understand the State and MDH Mobile Device and
Services Policies and agree to the conditions of these policies
.
________________________
___________________________
Administration
Printed Name Of Mobile device User
________________________
___________________________
Position/Title
Location:
___________________________
________________________________
Mobile device #:
Manufacturer Name/Model:
_______________________
___________________________
Serial # (ESN):
Vendor:
_______________________
____________________________
Inventory #:
Account #:
__________________________
____________________________
Mobile device User’s Signature
Date
Unit Telecommunication Monitor’s Name
Mobile device Return Receipt
**************************************************************************************
_________________________
________________
Telecommunications Monitor Signature
Date Equipment Returned
A SIGNED COPY OF THIS FORM SHALL BE GIVEN TO THE EMPLOYEE WHEN MOBILE DEVICE EQUIPMENT IS RETURNED
MDH POLICY 02.03.10
MOBILE DEVICE POLICY
Cross-Reference: General Services Administration- Central Services Division
_______________________________________________________________________________
MDH FORM 4622 (REVISED 07/ 2017)
______________________________________________________________________________________
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MDH POLICY 02.03.10 is effective October 30, 2003
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