Cell Phone Request/Liability

This form must be completed by a manager.

If at any time your equipment is lost or stolen, please contact Kurt Fire at 645-2731
immediately. A police report must be filed in order to receive a replacement.

Technology – Cell Phone Request Form
Manager’s Name
Manager's Name
First
Last
Phone Recipient’s Name
Phone Recipient's Name
First
Last
Will there be sensitive (PHI) information stored on this device?
New or Reissued?
Does this phone need wifi hotspot capabilities?

Please read below. Recipient will sign and agree to the these terms outlined below at device pickup:

By signing below, I authorize the aforementioned employee be assigned an electronic device as listed above, for one or all of the reasons listed below as per the Executive Order #2012-01 dated February 16, 2012:

    • The need for the employee to conduct work away from the regular worksite;
    • The need for the employee to conduct work-related research while away from the regular work site or outside of business hours;

City-provided cell phones are intended to be for City business use, but will allow for only personal emergency usage.

By my signature below, I hereby certify that I have read the statement above, and by signing this form, I agree to abide by this policy. I understand that abuse of this policy will result in termination of my device.
I have read the Health Insurance Portability and Accountability Act (HIPAA) Policy and agree to adhere to the standards as described in the document.

HIPAA Agreement
Mobile Device Policy

  1. This form must be completed by a program manager on behalf of their employee.
  2. Be sure to indicate whether a new phone is requested or an existing phone is reissued in the area provided.
  3. Recipient will be notified when the equipment is ready for pickup.

This page is updated regularly. Please check back for the latest updates and guidance about this and other Information Technology topics.