Request No.:
Firewall Modification Request
Information Technology Services Form ITS-8812 Rev E 5/27/08
Page 1 of 2
This form is to be used for requesting modifications to the campus firewall rules so that applications can be used securely across
various zones of the network. If you need assistance in filling out this form, contact your Information Technology Consultant (ITC):
http://www.calstatela.edu/itc. Please type or neatly print, and obtain all the required approval signatures. Instructions are available at
www.calstatela.edu/its/forms. Submit completed requests to the ITS Help Desk (LIB PW Lobby).
REQUESTOR INFORMATION
LAST NAME
FIRST NAME
MIDDLE NAME
EMPLOYEE ID NO. (Golden Eagle Card ID #)
OFFICE LOCATION (Bldg. & Room #)
OFFICE EXTENSION
DEPARTMENT
DEPARTMENT EXTENSION
COLLEGE/DIVISION
E-MAIL ADDRESS
ITC NAME
ITC EXTENSION
APPLICATION INFORMATION (this is the application/service that you want to work over the network)
1)
Application Title:
2)
Application Publisher:
3)
What will the application be used for?
4)
Where do you plan on using this application?
5)
Do you currently have the required license(s) for this application?
Yes
No
Will obtain license by (mm/dd/yyyy):
6)
Will this application be for permanent or temporary use? If temporary, provide termination date.
Permanent
Temporary If temporary, list the termination date:
7)
What type of data will be transmitted by this application (i.e., music, graphic images, database information, text, etc.)?
8)
If applicable, list the specific file extensions.
9)
Who/what needs access to this application and/or files it generates? Check all that apply.
All Students
All Faculty
All Staff/Dept Office(s)
All Open Access Labs
All Electronic Classrooms
Wireless Network
CSULA Modem Pool
CSULA Server Farm
Students in the
building
Faculty Office(s) in the
building
Staff/Dept Office(s) in the
building
Open Access Lab(s) in the
building
Electronic Classroom(s) in the
building
Research Office(s) in the
building
Common Management System (CMS)
Faculty Server - list name of server:
Staff Server - list name of server
Security Server - list name of server
Off Campus/Off Site – list hostname of site:
10)
Are User ID’s and/or Passwords required to use this application?
Yes
No
11)
Will this application generate and/or store any sensitive, personal, proprietary, or confidential information?
Yes
No
12)
If yes, how will you secure access to the data?
13)
Is this a new application to the campus?
Yes
No If no, who else or what other department is using this application?
Request No.:
Firewall Modification Request
Information Technology Services Form ITS-8812 Rev E 5/27/08
Page 2 of 2
CAMPUS SYSTEM INFORMATION
1)
System Name (hostname):
2)
Name of System Owner:
3)
Where is system equipment located?
4)
Who has access to the equipment location?
5)
Are application upgrades and system OS patches and fixes on a set schedule?
Yes
No If yes, what is the schedule (hourly / daily / monthly / yearly)?
NETWORK INFORMATION
Source IP Address(es)
Source Port(s)
Destination IP Address(es)
Destination Port(s)
Note: To get the IP Address(es), you can run “nslookup hostname” from your command prompt where “hostname” is the name of the source and
destination hosts. To find out specific port(s), you can run a port scan of the source and destination hosts to identify the port(s) required for your
application.
The protocol that this application uses is: (check one)
TCP
UDP
To get the protocol information, you must be logged onto the application server. Run “netstat –a” from the application server at the command
prompt. Look for the application port located in the second column labeled “Local Address”. When you locate the application port, the protocol will be
listed in the first column labeled “Proto” to the left of the “Local Address” column.
ACADEMIC SUPPORT (if applicable)
The ITC whose name appears on this form has contacted me about the requested software application and its use on the campus
network. I understand that allowing access to this application through our campus network traffic management control may pose a
security risk to the campus network as well as to other computers. I approve of access to the requested application being allowed on
our campus network.
DIRECTOR:
APPROVED
Reason for denial:
DATE:
DENIED
DEPARTMENT / BUSINESS UNIT ACKNOWLEDGEMENTS AND APPROVALS
I understand that allowing access to this application through our campus network traffic management control may pose a security risk to
my computer as well as to the rest of the campus network. I authorize Information Technology Services to do a security vulnerability
assessment of any system to be used for this application to identify any system oversights that could cause security risks to the
campus.
REQUESTOR SIGNATURE:
DATE:
Dept Chair/Manager Name (type or print)
Signature
Approved
Denied
Date
Dean/Director Name (type or print)
Signature
Approved
Denied
Date
If denied, give reason for denial: