U.S. USDA Form usda-ad-1143
AD-1143
1. SYSTEM/APPLICATION NAME
U. S. DEPARTMENT OF AGRICULTURE
Check one or more and complete the applicable section(s)
the applicable section(s))
Automated Cash Reconciliation Worksheet System
Corporate Property Automated Information System
Financial Data Warehouse
Financial Statements Entry Tool
Foundation Financial Information System
Help Expert Automation Tool
Integrated Acquisition System
Secure Remote
CORPORATE SYSTEMS ACCESS REQUEST FORM
2. FFIS APPLICATION NUMBER(S) (If Applicable)
USER INFORMATION (See Privacy Act Statement)
3. USER’S SSN
4. USER’S NAME (Last, first, middle initial)
5. USER’S TITLE OR CONTRACTOR *
6. USER’S MAILING ADDRESS WITH ZIP CODE
7. AGENCY
9. USER’S E-MAIL ADDRESS
10. USER’S PHONE NUMBER
8. OFFICE
11. MANAGER’S PHONE NUMBER
*See special instructions
12. OLD NAME (Last, first, middle initial)
ACTION REQUESTED
U
13. NEW NAME
(Last, first, middle initial)
NAME CHANGE
14. (Check all that apply):
ACCESS
15. USER ID(S) (Include NFC User ID, if applicable)
Add User
Delete User
Modify User Profile
Agency Cross-Service Access
AUTOMATED CASH RECONCILIATION WORKSHEET SYSTEM (ACRWS) ACCESS
16. USER’S ACRWS ROLE (Check all that apply)
17. ACRWS APPROVER
(Sign when action has been completed)
Reporter
ACRWS 52
Auditor
ACRWS 52 Brio
Importer
ACRWS 53
Approver
ACRWS 53 Brio
18. DATE
CORPORATE PROPERTY AUTOMATED INFORMATION SYSTEM (CPAIS) ACCESS
19. USER’S CPAIS ROLE
RPA ROLES
GENERIC ROLES
RPM ROLES
RPM_LEASE_MGR
CONTACT_MGR
RPA_STREAM _MGR
RPM_PROPERTY_MGR
CPAIS_READ_ONLY
RPA_DISPOSAL_MGR
RPM_WK_ITEM_MGR
RPA_LOCAL_MGR
RPM_OCCUPANCY_MGR
SYSTEM ADMINISTRATOR ROLES
CPAIS_ADMIN_MGR
CPAIS HQ_MGR
RPM_CO_LOCATION_MGR
21. RPM/RPA APPROVER (Sign when action has been completed)
20. CPAIS TRAINING RECEIVED ? (If yes, enter date completed)
Yes
No
AD 1143 (Rev. 7/04)
1
HELP EXPERT AUTOMATION TOOL (HEAT) ACCESS
22. USER’S HEAT ROLE
23. HEAT TRAINING RECEIVED?
(If yes, enter date completed)
Secure Remote
HEAT Call Logging
HSS (HEAT Self Service)
Yes
No
Yes
No
HEAT User Roles
Manager’s Console
Provides Customer Support
Answer Wizard
Customer
HPK (HEAT Plus Knowledge)
Other: _______________________________
24. HEAT APPROVER
(Sign when action has been completed)
INTEGRATED ACQUISITION SYSTEM (IAS) ACCESS
25. USER’S IAS ROLE (Check all that apply)
26. REQUISITI ON APPROVAL AMOUNT
Requisitioner
Receiver
Requisition Approver
Invoice Entry Clerk
Budget Approver
Payment Approving Officer
Commitment Error Manager
Payment Approving Error Manager
Purchasing Specialist/Contracting Officer
Interface Manager
Supervisory Contracting Officer
Payment Status Reviewer
Obligation Error Manager
Other ________________________________
27. ACQUISITION WARRANT AMOUNT
28. CROSS AGENCY SERVICE TO (If Applicable)
SPECIAL INSTRUCTIONS
29. SPECIAL INSTRUCTIONS
USER ACKNOWLEDGEMENT
I have read the automated information systems security rules and understand the security requirements of the automated information systems and/or
applications described on this form. I understand that any violation of these rules may result in disciplinary action, removal from the agency/USDA, and/or
criminal prosecution.
30. USER’S SIGNATURE
32.
31. DATE
33. DATE (Initiated or completed)
BACKGROUND INVESTIGATION
U
34. PRINT MANAGER’S
NAME
Initiated
Completed
AUTHORIZATION
U
User’s Manager – I certify this user has received
35. MANAGER’S SIGNATURE
security instructions for the systems and/or applications
indicated, and I approve his/her access to these systems
and/or applications and the associated user profiles.
37. SECURITY ADMINISTRATOR
36. DATE
ACTION TAKEN
U
38. DATE
39. SECURITY ADMINISTRATOR NOTES
PRIVACY ACT NOTICE
In compliance with the Privacy Act of 1974, the following information is provided: Solicitation of your Social Security Number is authorized by Executive Order 9397 of
November 22, 1943 and 5 U.S.C. 301. The primary purpose of requesting the Social Security Number (SSN) is to properly identify the employee. Many employees have
similar names and the furnishing of the SSN will enable USDA to identify authorized users of USDA’s computer systems. The information will be used by offices and
employees who have a need for the information in the performance of their official duties. The information will not be disclosed outside USDA. Disclosure of your SSN and
other information is mandatory. Failure to provide the requested information will result in the denial of the requested computer access authority.
AD 1143 (Rev. 7/04)
2