Ok-Screen End User Security Agreement Form - Oklahoma

This "Ok-Screen End User Security Agreement Form" is a document issued by the Oklahoma State Department of Health specifically for Oklahoma residents with its latest version released on January 31, 2014.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Oklahoma State Department of Health.

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Oklahoma State Department of Health
Oklahoma Screening and Registry Employee Evaluation Network (OK-SCREEN)
End User Security Agreement
Facility/Company Name: __________________________________________________________________
Please attach a list of all related entities for which this account shall be authorized. Include the applicable facility/
provider license number for each facility. If you are applying for only one facility enter the license number below.
License Number: __________
(The facility/provider license number for each facility to be accessed under this
account must be provided. Otherwise, indicate staffing agency ____ or independent contractor ____ as
applicable. )
Please submit only one Provider End-User Security Agreement. The holder of the account established by this
agreement will act as an administrator of accounts for all related entities identified with this application. The
account holder will be responsible for collecting and maintaining End-User Security Agreements for any
additional accounts created in OK-SCREEN for the identified related entities and for issuing and maintaining
those accounts. The holder of the account established by this agreement may create additional administrator
accounts for their related entities.
First Name: ________________________________________________
Middle Initial: ______
Last Name: __________________________________________________________________________
Address: ____________________________________________________________________________
Proposed User Name: __________________________ Phone#: _____________________________
Email: ______________________________________________________________________________
Provider End User Security Agreement
The Oklahoma Screening and Registry Employee Evaluation Network (OK-SCREEN) is password protected. You
must register and secure a username and password before you access the secured site. Username and passwords
are not to be shared at any time. All users must secure a user name and password from an authorized Oklahoma
State Department of Health (OSDH) OK-SCREEN Systems Administrator or Provider User Administrator. You
and your company are entirely responsible for maintaining the confidentiality of your username and password.
Provider User Administrators are responsible for disabling the user accounts of terminated employees.
Furthermore, you and your company are entirely responsible for all activities that occur on this site. You or your
company must notify the OK-SCREEN program office immediately of any known or suspected unauthorized use of
your username and password or any other breach of security. Contact the OK-SCREEN program office at
(405) 271-3598 or send an E-mail to okscreen@health.ok.gov.
My signature acknowledges and confirms that I have read, understand, and accept the terms and conditions as
stated in this Provider End User Security Agreement form.
________________________________________
___________________________
Signature of Account Applicant
Date
THIS FORM REQUIRES THE SIGNATURE OF AN AUTHORIZED OFFICER OF THE LICENSED OPERATING
ENTITY. THIS IS GENERALLY NOT THE ADMINISTRATOR
___________________________________________
___________________________
Printed Name of Authorized Person Signing
Official Title or Position
for the Licensed Operating Entity
___________________________________________
___________________________
Signature of Authorized Person
Date
Fax or e-mail the completed form to 405-271-1566 / okscreen@health.ok.gov
th
St. ∙ Oklahoma City, OK 73117 ∙ Ph. (405) 271-3598 ∙ Fax. (405-271-1566)∙ Ver 01/31/2014
OK-SCREEN ∙ Rm 139 ∙ 1000 NE 10
Oklahoma State Department of Health
Oklahoma Screening and Registry Employee Evaluation Network (OK-SCREEN)
End User Security Agreement
Facility/Company Name: __________________________________________________________________
Please attach a list of all related entities for which this account shall be authorized. Include the applicable facility/
provider license number for each facility. If you are applying for only one facility enter the license number below.
License Number: __________
(The facility/provider license number for each facility to be accessed under this
account must be provided. Otherwise, indicate staffing agency ____ or independent contractor ____ as
applicable. )
Please submit only one Provider End-User Security Agreement. The holder of the account established by this
agreement will act as an administrator of accounts for all related entities identified with this application. The
account holder will be responsible for collecting and maintaining End-User Security Agreements for any
additional accounts created in OK-SCREEN for the identified related entities and for issuing and maintaining
those accounts. The holder of the account established by this agreement may create additional administrator
accounts for their related entities.
First Name: ________________________________________________
Middle Initial: ______
Last Name: __________________________________________________________________________
Address: ____________________________________________________________________________
Proposed User Name: __________________________ Phone#: _____________________________
Email: ______________________________________________________________________________
Provider End User Security Agreement
The Oklahoma Screening and Registry Employee Evaluation Network (OK-SCREEN) is password protected. You
must register and secure a username and password before you access the secured site. Username and passwords
are not to be shared at any time. All users must secure a user name and password from an authorized Oklahoma
State Department of Health (OSDH) OK-SCREEN Systems Administrator or Provider User Administrator. You
and your company are entirely responsible for maintaining the confidentiality of your username and password.
Provider User Administrators are responsible for disabling the user accounts of terminated employees.
Furthermore, you and your company are entirely responsible for all activities that occur on this site. You or your
company must notify the OK-SCREEN program office immediately of any known or suspected unauthorized use of
your username and password or any other breach of security. Contact the OK-SCREEN program office at
(405) 271-3598 or send an E-mail to okscreen@health.ok.gov.
My signature acknowledges and confirms that I have read, understand, and accept the terms and conditions as
stated in this Provider End User Security Agreement form.
________________________________________
___________________________
Signature of Account Applicant
Date
THIS FORM REQUIRES THE SIGNATURE OF AN AUTHORIZED OFFICER OF THE LICENSED OPERATING
ENTITY. THIS IS GENERALLY NOT THE ADMINISTRATOR
___________________________________________
___________________________
Printed Name of Authorized Person Signing
Official Title or Position
for the Licensed Operating Entity
___________________________________________
___________________________
Signature of Authorized Person
Date
Fax or e-mail the completed form to 405-271-1566 / okscreen@health.ok.gov
th
St. ∙ Oklahoma City, OK 73117 ∙ Ph. (405) 271-3598 ∙ Fax. (405-271-1566)∙ Ver 01/31/2014
OK-SCREEN ∙ Rm 139 ∙ 1000 NE 10

Download Ok-Screen End User Security Agreement Form - Oklahoma

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