Form EARC-2 "Access Request Form for Salesforce Government Cloud" - New Jersey

What Is Form EARC-2?

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

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the New Jersey Department of Human Services;
  • 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 fillable version of Form EARC-2 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Human Services.

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Download Form EARC-2 "Access Request Form for Salesforce Government Cloud" - New Jersey

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New Jersey Department of Human Services
Division of Aging Services
ACCESS REQUEST FORM FOR SALESFORCE GOVERNMENT CLOUD
Acute Care Provider EARC User
New
Update
Request Type:
Date:
Section A: To be completed by the person requesting access
First Name:
MI:
Last Name:
Mother's Maiden Name:
Work Phone #:
Work E-Mail:
I have read the Computer User
Signature:
Responsibility Acknowledgement
on pg. 2 of this form and
agree to comply.
Date:
Section B: To reinstate login
Disabled User ID:
Section C: To be completed by the supervisor
Provider:
Street:
City:
State:
Zip Code:
First Name:
MI:
Last Name:
Title:
Work Phone #:
Supervisor W ork E-Mail:
Work Fax #:
Supervisor Signature:
Date:
ISR Name:
ISR Signature:
Date:
1
EARC-2
JUL-2019
New Jersey Department of Human Services
Division of Aging Services
ACCESS REQUEST FORM FOR SALESFORCE GOVERNMENT CLOUD
Acute Care Provider EARC User
New
Update
Request Type:
Date:
Section A: To be completed by the person requesting access
First Name:
MI:
Last Name:
Mother's Maiden Name:
Work Phone #:
Work E-Mail:
I have read the Computer User
Signature:
Responsibility Acknowledgement
on pg. 2 of this form and
agree to comply.
Date:
Section B: To reinstate login
Disabled User ID:
Section C: To be completed by the supervisor
Provider:
Street:
City:
State:
Zip Code:
First Name:
MI:
Last Name:
Title:
Work Phone #:
Supervisor W ork E-Mail:
Work Fax #:
Supervisor Signature:
Date:
ISR Name:
ISR Signature:
Date:
1
EARC-2
JUL-2019
Computer User Responsibility Acknowledgement
Government agencies have a particular responsibility to maintain the confidentiality and accuracy of
the data that is stored in its computer and electronic systems. The Division of Aging Services (DoAS)
will enforce a policy of individual user responsibility for access to and use of its information and
systems.
Users must notify DoAS immediately if they have left the provider organization or if any contact
information has changed. Users must contact DoAS at EARCRegistration@dhs.state.nj.us.
Users shall stay current with updates to the EARC process by checking the website at
www.state.nj.us/humanservices/doas.
Users shall use the online EARC system approved by DoAS, which administers the EARC process .
Users shall help ensure the EARC is completed as truthfully and accurately as possible.
Users shall adhere to the requirements of all applicable state and federal laws, rules, and regulations
pertaining to the confidentiality and disclosure of information and records. All consumer/applicant
information must be kept confidential under federal and state law. Users shall not give information to
anyone unless requested by the consumer/applicant.
Users must use appropriate safeguards to prevent the disclosure of consumer/applicant protected
health information and other consumer/applicant personal information. Users also shall protect
against reasonably anticipated threats to confidentiality. Users shall ensure that consumer/applicant
information is kept confidential and is stored in a secure location. All information that is no longer
needed by the provider organization shall be shredded. Users shall follow the comprehensive
information privacy and security program of their provider organization.
Users must notify DoAS immediately in the event of an improper disclosure of consumer/applicant
protected health information or other personal information. In such event, users must contact
DoAS at 609-588-6675.
In addition, by signing this form, I acknowledge that I understand the following Computer User
Responsibilities:
• Computer system passwords are assigned to each individual computer user for that individual's use
only.
• Computer system passwords must be kept confidential by the assigned individual. Passwords are
not to be shared with anyone, including supervisors.
• Use of computer systems shall be limited to YOUR job-related duties only.
• Computer users must sign-off (log-off) from password protected computer systems if they are not
physically present. Personal computer users may activate a confidential password-protected
screensaver.
• Computer users that fail to adequately protect their logins, passwords and confidential data from
inappropriate disclosure/use/theft are personally liable for any potential consequences.
User accounts not used for 60 days will be automatically deleted from the system. A User
whose account was deleted will need to submit a new Access Request Form to regain access.
DoAS reserves the right to revoke a User’s account for breach of this agreement.
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EARC-2
JUL-2019
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