CIRS Report Request
A new request or revision to ___ _(old title) (Complete all Boxes)
Rerun of existing report (Complete boxes 1,2,3,6,7,8,14,15)
1. Date of request: 2. Working title of report: 3. Report needed by: (Date)
4. Report Frequency: 5. This request is for:
One time Daily Weekly A printed report A down-loaded report
Monthly Quarterly Other ______________________ Information only Excel or Text file
6. Who will physically use this report?
Name Title
Signature: Date:
7. How will report be discarded when no longer needed? 8. Name of Departmental Information Security Designee
9. How will report be used? (Justification and Purpose)
10. I desire to meet with the CIRS coordinator to finalize report criteria.
11. What data elements are needed and in what sequence?
See attached printout sample
12. What sort order? 13. What definitions are needed? (See data element dictionary)
14. Department Manager Approval: (Signature indicates request is of direct use to department and that department will safeguard
the printed report)
Signature: Date:
15. Dean/Senior Manager Approval:
Signature: Date:
CIRS Coordinator Use:
Remarks: Assigned to ____________________________________________________________ Info user group review
Documented Charge to Run Report ______________________________________________
CIRS catalog (Title) __________________________________________________Date completed:______________________
file: \OED:\forms\CIRS.doc
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