Suffolk Governance Project Request Form
Project Title:
Date Submitted:
Requestor’s Name:
Requestor’s Email:
Requestor’s Work Extension:
Requesting Department:
Contact Going Forward:
Contact’s Work Extension:
Departmental Funding:
Department is funding this project
Yes
No
Approved Budget Amount
Unsure
.
Completion Date: (project to be completed by)
Project Sponsor’s Name:
Project Sponsor’s Work
Extension:
Project Description: (describe the business problem you need to solve and what you want this solution to accomplish)
How will this project help achieve the Strategic Plan? (why should Suffolk University pursue this Project and how it aligns with the
University Strategic Plan)
Resource Projections: (identify who you think should be involved from what departments. Also, will a vendor or 3rd party be involved?)
Department/Vendor
User(s) projected
.
.
Goals and Objectives: (How will this project benefit the university and/or end user satisfaction?)
Success Criteria: (What are the measurements to be used to determine project success, and who will sign off?)
.
Suffolk Governance Project Request Form © Copyright Suffolk University
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Please include any documentation that will support this project request
Acknowledgement/Approval Signatures on Page 3
Suffolk Governance Project Request Form
Confidential Information: (Will your project contain confidential information – SSN, Financial Accounts, Credit Cards, RAM Cards, FERPA
data, or required by contract or law. For more information about Suffolk Confidential information please refer to the Written Information
Security Policy )
Will this project contain or process
any Confidential Information:
Yes
No
If yes, select ALL types of data that apply:
Unsure
Will this service be publicly available?
Social Security Number
Financial Account Numbers
Yes
No
Credit Card Processing
FERPA
RAM Card
HIPAA
By Contract or Law
Other
Unsure
Data Storage Location: (Where will you store and or output data and the formats for this data)
Data will be stored and outputted in the following formats: (Check all that apply)
Will be stored in Paper Format
Will be stored in Electronic Format
Will be output in Paper Format
Will be output in Electronic Format
Planned Location of Data (if known please list)
.
Third Party: (note any third parties involved in supplying, processing or maintaining any data or software required by this project)
Plan to use a Third Party as part of this project to process store or send data to/from.
Yes
No
Unsure
Vendor Name
Current Vendor Contact if available
.
Users Who Have Rights Or Access: (Check the appropriate boxes. Enter the username(s) who will review or maintain approve access)
Will this project require multiple users to have access to administer the data
Yes
No
Unsure
Department Administrator(s) who will approve user accounts and access levels
Name
Current Title
.
Regulations: (Is the project required to conform to any regulations (i.e. MA 201 CMR, Red Flags, PCI, HIPAA, Sarbanes–Oxley,
etc.).
Will this project be required to conform to any Federal/State regulations?
Yes
No
Unsure
.
201 CMR 17
Red Flag Rules
FERPA
HIPAA
PCI
Suffolk Governance Project Request Form © Copyright Suffolk University
GBLA
Other
Page 2 of 3
Please include any documentation that will support this project request
Acknowledgement/Approval Signatures on Page 3
Suffolk Governance Project Request Form
This form is not complete without the following signatures. Please email scanned copy with signatures to
ITGovPM@suffolk.edu or send a hard-copy via interoffice mail to the PMO and keep the original.
Project Requestor’s Signature:
________________________________
Date: _______________________
Manager’s Signature _______________ __________________________________ Date: ______________________
(for Submission Acknowledgement)
VP/Sponsor’s Signature:
(for Submission Acknowledgement)
Project Completion Sign-off by
_________________________________ Date: ______________________
Sign-off Title
Suffolk Governance Project Request Form © Copyright Suffolk University
Page 3 of 3
Please include any documentation that will support this project request
Acknowledgement/Approval Signatures on Page 3