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 Print Form