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IT Service Request Form

Tell us how we can help you. Please be as detailed as possible about your IT Service Request
Please be as detailed as possible about your Video Project
Please describe where filming or recording of video should take place
Please select the type of folder request you would like to make
New Folder Access Disclaimer

As an employee, researcher, or responsible administrator affiliated with Duke University's School of Nursing, I understand that in order to conform to established HIPAA and organizational security guidelines, I am required to notify the Center for Information Technology and Distance Learning (CITDL) prior to uploading or storing any electronic documentation which may contain protected health information (PHI) or other data which may be sensitive. Duke University School of Nursing strictly prohibits the electronic storage of social security numbers.

Existing Folder Access Disclaimer
As an employee, student, or responsible administrator affiliated with Duke University's School of Nursing, I understand that in order to conform to established HIPAA and organizational security guidelines, I am required to notify the Center for Information Technology and Distance Learning (CITDL) prior to uploading or storing any electronic documentation which may contain protected health information (PHI) or other data which may be sensitive. Duke School of Nursing strictly prohibits the electronic storage of social security numbers.
Protected Health Information Disclaimer

PHI Protected Health Information is defined as 

“Health information means any information, whether oral or recorded in any form or medium, that

(A) is created or received by a health care provider, health plan, public health authority, employer, life insurer, school or university, or health care clearinghouse; and
(B) relates to the past, present, or future physical or mental health or condition of any individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual.”

The following identifiers of the individual or of relatives, employers, or household members of the individual, are removed:

(A) Names;
(B) All geographic subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of the Censue:

(1) The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and
(2) The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000.

(C) All elements of dates (except year) for dates directly related to an individual, including birth date, admission date,, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older;
(D) Telephone numbers;
(E) Fax numbers;
(F) Electronic mail addresses;
(G) Social security numbers;
(H) Medical record numbers;
(I) Health plan beneficiary numbers;
(J) Account numbers;
(K) Certificate/license numbers;
(L) Vehicle identifiers and serial numbers, including license plate numbers;
(M) Device identifiers and serial numbers;
(N) Web Universal Resource Locators (URLs);
(O) Internet Protocol (IP) address numbers;
(P) Biometric identifiers, including finger and voice prints;
(Q) Full face photographic images and any comparable images; and
(R) Any other unique identifying number, characteristic, or code, except as permitted by paragraph

 I have reviewed, understand, and agree to comply with the above

PHI Information

If your project collects Protected Health Information (PHI) or Social Security Numbers (SSN), please check the "Yes" box below and select all the types of PHI your project collects.

Help us understand the nature of the Protected Health Information you will be collecting.
It is extremely important that you answer these questions accurately so that we may comply with HIPAA guidelines

New Folder Request Information
User Folder Access Control
Please use the section below to add additional users who require access to your folder.
User 1
User 2
User 3
User 4
User 5
User 6
User 7
User 8
User 9
Please enter the name and email address of the folder owner. In addition, please provide the reason for access to the folder.
Name of the folder for which you are requesting access
Please provide the reason you need access to the requested folder