Polk County Health Net


User: Pass: Request Access

Request for access to restricted web pages.

Four levels of access are available:

Security Level	Color	Authorized Users	Description
UNCLASSIFIED	Grey header or no header	General public	Can be viewed and shared with the general public without risk of breach of confidentiality or security risks. Copyright laws may still apply.
CONFIDENTIAL	Blue header	Government employees and emergency responders	Would cause "damage" to security or breach community confidentiality if released to the general public.
SECRET	Red header	NA	This level is not currently used.
TOP SECRET	Yellow header	Health department employees only	Would cause "exceptionally grave damage" to security or breach individual confidentiality if released to the general public.

Request Form:

Complete the following form to request access to the appropriate security level. This form may also be used for forgotten usernames and/or passwords. Usually, within 24-hours, confirmation of your submitted information will be requested from a known source (i.e. your employer). Once a response is received, your request will be processed and a confirmation email will be sent to the address provided. All passwords and access expire after 12 months. A notice will be sent to each access holder as a reminder to return to this form and complete another request for access.

All fields below are required.

1.	First name:
2.	Last name:
3.	Agency:
4.	Email address:
5.	Phone number:	(format: ###-###-####)
6.	Requested password:	(Must be at least 8 characters in length and can include letters, numbers, and symbols. Password will be case-sensitive.)
7.	Retype password:

By submitting this request for access, I understand and agree with the following:

I understand the use of restricted access is for the protection of the public to ensure responses to disasters and emergencies are not compromised and is for the protection of the privacy of response personnel as contact information and other private information may be stored in restricted databases for use during routine, official activities, and during a disaster or emergency.
I agree not to disclose any information found within this database, my username, or my password to anyone else for any reason and take all reasonable measures to prevent said disclosure. All requests for information should be forwarded to the appropriate agency administrator.
I understand that any documents, printed or otherwise, stored away from this system carries the same need for security. Hard-copy and electronic-copy documents retrieved are still to be treated as restricted information for my personal use only and should be destroyed after use.
I understand that my obligation under this agreement will continue after my termination of employment and/or association with the agency listed above. I agree to immediately notify the webmaster of my termination and return or destroy all hard-copies and electronic-copies and my access to this system may be revoked.
I understand that my username and password are the equivalent of my signature and that I am accountable for all entries and actions recorded during their use.

Violation of this agreement may result in, but not limited to, the following:

Denial of access,
Notification of agency administrator listed above,
Penalties under State and Federal laws and regulations, and/or
Any combination of the above.

By clicking "Submit" below:

I consent to the Polk County Health Center contacting the agency listed above for association verification,
I have read and understood the above access agreement, AND
I agree with all items and terms listed in the access agreement.

Polk County Health Center
(417) 326-7250 / (417) 326-2766 fax

1317 W Broadway St, Bolivar, MO 65613

© 2008 Polk County Health Center, Bolivar, Missouri. All rights reserved.
All services are provided on a nondiscriminatory basis.
An equal opportunity / affirmative action employer.

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