HomeMy WebLinkAbout2020-015Department of Economic Opportunity
All fields MUST be
Subrecipient Enterprise Resource Application (SERA)
completed for
Security Agreement / Confidentiality Form for Subrecipients
access to be
granted.
Section A — Re uestor's Information
User Contact Information
Primary Unit Information
First Name: Matt
Organization Name: Indian River County
Middle Name:
Address: 1801 27th Street
Last Name: KalaD
City: Vero Beach
Job Title: Long Range Planner
State: FL Zip: 32960
Phone Number: 772-226-1243
Region: County: Indian River County
Fax Number: 772-978-1806
Unit(s):
Email: mkalapCa)ircgov.com
Section B — Level of Access Requested
PROGRAM
PROGRAM
PROGRAM
READ
FULL
REASON FOR ACCESS
GROUP
SPECIFIC
ONLY
ACCESS
WORKFORCE
All Workforce Programs
❑
❑
ESS
❑
❑
WAP
❑
LIHEAP
❑
CSBG
❑
CDBG
❑
CDBG
®
Reporting, Request for Funding
CDBG — DR (List below)
❑
Is
❑
2
b
Section C — Subreci lent Access Approval E
Security / Confidentiality Agreement
Your supervisor has authorized you to have access to sensitive data through the use of the Department of Economic Opportunity (DEO) Information s
and related media (i.e. printed reports, system inquiries, etc.). All confidential information, particularly Personally Identifiable information (PII) are su o
the protection of federal, state and local laws and are to be protected accordingly. Unauthorized access, use, disclosure, modification, and/or destru of
confidential information is a crime under state and federal laws, including, but not limited to The Florida Computer Crimes Act, Chapter B15 Florida S 4,
(F.S.) and Florida's Unemployment Compensation Law, Chapter 443, F.S.
t�
*I certified that I have read the security/confidentiality statement printAabovher certify and understand that unauthorized access, use modifitleh,
dissemination, and/ r destruction of confidential informati becrime and/or result in disciplinary action take t me. I
ackgo dge th ve received, read and that I under nd Ch teav eceived any ne clarification f supervisor.
/
Requestor's Signatidre Supeisor' Signature C / Executive Di or's Signature
Matt Kalap ` Jaso E. rown Susan Adams
Print/Type Name Date !/� /Zd 2O Print4,yKe Name Date 1/22/2020 Print/Type Name Date 1/22/ 2020
Section D — DEO Authorization
SERA ROLE SERA PROFILE
DEO Program Approval
Signature Print Name Date
DEO BFM Approval
Signature Print Name Date
DEO Security Officer's Approval
Signature Print Name Date
DEO IT: Activated Inactivated:
Date Date