Page 1 of 3 Banner Account Request Form - Version 3.1
Request for Banner User Account
(Note: Please Read and sign the Confidentiality Statement, obtain signature of your Supervisor)
Albany State University has compiled certain proprietary information about its students (hereinafter “Confidential Information”) in
an information system known as “Banner” (the “System”).
Such Sensitive and/or Confidential Information are not public knowledge but it is proprietary and private.
Confidential Information is protected under a federal law known as the Family Educational Rights and Privacy act of 1974, as
amended (“FERPA”), and persons may access such Sensitive and/or Confidential Information only in the legitimate educational
interest of the student. I also acknowledge that there are additional federal laws as it relates to the protection of student
information, e.g. HIPAA, Red Flags Rules, etc.
My job duties require that I have access to Sensitive and/or Confidential Information in the System. My signature on this document
evidences that I understand the need to ensure that my personal and work activities do not violate the confidentiality of the
Sensitive and / or Confidential Information, and that I safeguard the non-disclosure of this proprietary and private Information.
I agree as follows:
Definition of Confidential Information. As used in this Agreement, the term “Confidential Information” means records
which contain individually identifiable information about students (except information classified as directory information).
Training. I will become familiar with, and will periodically review, the requirements imposed by FERPA, HIPAA, Red Flag
Rules, and other as applicable by reviewing the information which is available to me. If I do not understand what is required
of me under FERPA, HIPAA, Red Flag Rules, and others as applicable, I will ask my manager for further clarification.
Limited Information. I agree that I will only access Sensitive and/or Confidential Information which I need to complete my
assigned job duties.
Use of the Sensitive and/or Confidential Information. I agree to use the Sensitive and/or Confidential Information only to
perform my job duties. I will not make any personal copies of the proprietary and private information. I will not disclose these
types of information to third parties or use this information for my own purposes.
Ownership of the Sensitive and/or Confidential Information. All proprietary and private Information is and remains the
property of Albany State University.
No access by others. I will not share my ID or my PIN with any other person or party. In so doing I will be subject to
disciplinary action, up to and including termination of my employment.
Consequences of Failing to Follow Regulatory and Compliance Requirements. I understand and agree that failure
to follow the requirements of FERPA, HIPAA, Red Flag Rules, and others as applicable can be grounds for disciplinary
action, up to and including termination of my employment.
No Contract of Employment. This acknowledgment will not be construed as a contract of employment.
I have read and acknowledged the Confidentiality Statement above and agree to abide by all applicable laws and
restrictions that govern use to this enterprise system.
I have attached a description of the functions I am assigned to perform and have indicated the access needed
in Section 3.
SECTION 1: User requesting access completes Section 1.
SECTION 2: Approval by Manager/Supervisor. Signature is required
SECTION 3: Mark security levels and select role(s). Signature is required of the business owner in charge of each Specific Area.
Please fill up Specific Module Details in the space given below this section with access rights Modify (M) or Query (Q) information.
(Note: Mark all applicable boxes, even if privileges may already have been assigned.)
SECTION 4: Signature of VP for Enrollment Management. This is mandatory.
SECTION 5: Requires Signature of VP for ITS (Only IT Staff)
SECTION 6: Completed by ITS.