Free None - Wisconsin

DEPARTMENT OF HEALTH & FAMILY SERVICES Division of Public Health DPH 44010 (03/02)

STATE OF WISCONSIN Bureau of Occupational Health HFS 163, Wis. Adm. Code

LEAD-FREE / LEAD-SAFE PROPERTY REGISTRY, TRAINING COURSE, CLASS AND ROSTER DATABASE ACCESS APPLICATION
Complete a separate application for each employee for which your company is requesting access to enter data in the Lead-Free / Lead-Safe Property Registry, or the Training Course, Class and Roster databases. Before completing this form, the applicant must have registered with the State of Wisconsin WEB-based process, created a unique Wisconsin User ID and provided an individual user email address. Type of Access Requested EMPLOYEE INFORMATION
Name Address City Telephone Number Email Address WI User ID State Zip+4 DHFS Lead Certification Number Lead-Free / Lead-Safe Property Registry Training Course, Class and Roster Database

COMPANY INFORMATION
Company Name Address City Telephone Number State Company Email Address Zip+4 DHFS Lead Certification Number

COMPANY ACCESS AUTHORIZATION ADMINISTRATOR
Name of Authorization Administrator DHFS Lead Certification Number

Telephone Number

Email Address

SIGNATURE ­ Access Authorization Administrator

Dated Approved

DATABASE ACCESS USER ACCEPTANCE AGREEMENT - EMPLOYEE The Wisconsin User ID, password, and the individual email address, are the keys to doing secure business with the State of Wisconsin over the Internet. This information should be considered as important as your signature. Much of the information collected by the State of Wisconsin is confidential and is managed accordingly. The State has taken appropriate steps to safeguard the integrity of information it obtains and to prevent access by unauthorized persons. To ensure the integrity and security of the information you are authorized to manage, do not share your User ID or password with anyone. It is your obligation to protect it by keeping it confidential and known only to you. Information systems and data stored managed by the State of Wisconsin are governed by Federal and State laws, rules and regulations. Violators who mismanage their access authority and responsibility in working with state data systems may be subject to prosecution, fines or other sanctions. By my signature, I agree to abide by the security requirements stated above when approval for access to the Lead-Free / Lead-Safe Property Registry and/or Training Course, Class and Roster Database is granted.

SIGNATURE - Employee Requesting Access FOR DHFS OFFICE USE ONLY Access Granted SIGNATURE ­ DHFS Staff

Date Signed ACCESS AUTHORIZATION APPROVAL Training Course, Class and Roster Database Date Approved

Lead-Free/Lead-Safe Property Registry