Firewall Services Request
Information Technology Services – Network Department
This form is to request modifications to the Stephen F. Austin State University campus firewall rules. In order to provide access from
external sources to machines within the University’s network, this form must be submitted. You may email form to
ITSecurity@sfasu.edu but completed form with signatures must be turned in within 10 business days to Telecommunications/Network
Dept Box 6095.
CONTACT INFORMATION
By providing your contact information, the network department will have the necessary information to contact the
appropriated people if a situation rises.
ADMINISTRATIVE/REQUESTOR CONTACT (FACULTY/STAFF)
System/Host Owner
FIRST NAME
MIDDLE NAME
DEPARTMENT
DEPARTMENT EXTENSION
COLLEGE/DIVISION
OFFICE LOCATION(BLDG/ROOM)
OFFICE PHONE NUMBER
EMERGENCY PHONE NUMBER
LAST NAME
EMAIL ADDRESS:
TECHNICAL CONTACT
LAST NAME
System/Host Owner
FIRST NAME
MIDDLE NAME
EMAIL ADDRESS:
OFFICE PHONE NUMBER
EMERGENCY PHONE NUMBER
NETWORK INFORMATION
General system information is needed to open the port on the firewall. Allowing access through the firewall poses security risks. It is
the responsibility of the host owner to ensure the machine is fully patched for any known vulnerabilities. It is the responsibility of the
host owner to ensure that the machine meets all state and federal requirements.
SYSTEM INFORMATION
SYSTEM/HOST NAME
IP ADDRESS
NAME OF SYSTEM OWNER(if not the Admn/Tech Contact)
MAC ADDRESS:
EQUIPMENT LOCATION:
If NOT located in the Boyton Bldg or Network Dept Cold Room:
Who has access to location? Describe physical security.
Operating System Name/Version
Upgrades/System patches on a set schedule:
Yes
No
If yes, what is the schedule (hourly/daily/monthly/yearly)
Does it store/generate confidential information:
Is it a webserver: Yes
Yes
If Yes
TAC 206 Compliant Section 508
Yes
No
No
If Yes: How will the data be secure? Encryption? SSL
No
Firewall Services Request
Information Technology Services – Network Department
FIREWALL ENTRY INFORMATION
SOURCE IPADDRESS(ES)
(if not “ANY”)
DESTINATION IP ADDRESS
-HOST-
DEST. PORT/ PROTOCOL
(UDP/TCP/IP/ICMP etc)
Permanent:
Temporary:
End Date:
DESCRIPTION OF SERVICE:
APPROVAL
DEPARTMENT/BUSINESS UNIT ACKNOWLEDGEMENT AND APPROVALS
I understand that allowing access to this application/host through our campus firewall may pose a security
risk. I authorize the Information Technology Services (ITS) and/or Network Department to disable the
firewall entry in the event that a security risk arises when the System Owner or Technical Contact cannot
be contacted. I further authorize ITS to do a security vulnerability assessment or penetration test to meet
State requirements to help identify any system oversights which may cause security risks.
REQUESTOR
SIGNATURE: ________________________________________DATE:___________________________
Dept Chair/Manager Name
Signature
Approve
Denied
Date
Dean/Director Name
Signature
Approve
Denied
Date
If denied, give reason for denial
Network Department Use
Date Received:
Firewall Entry Date:
Completed By:
Notified Requestor On:
Email
Phone
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