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</head> <body class="html not-front not-logged-in page-node page-node- page-node-46 node-type-webform ucsf-b1gfoot font--header--helveticaneue profile--grid no-sidebar no-sidebar--right" > <div id="skip-link"> <a href="#main-content" class="element-invisible element-focusable">Skip to main content</a> </div> <div id="page-wrapper"> <div id="page"> <div class="ucsf-top-header row-full-width no-logo"> <div class="inside"> <ul class="menu"> <li class="first"><a href="https://www.ucsf.edu">University of California San Francisco</a></li> <li><a href="https://www.ucsfhealth.org/">UCSF Health</a></li> <li><a href="https://www.ucsf.edu/search" title="">Search UCSF</a></li> <li><a href="https://www.ucsf.edu/about">About UCSF</a></li> </ul> </div> </div> <div id="header" class="row-full-width"> <div class="inside clearfix"> <h1 id="site-name"> <a href="/" title="Home" rel="home"> FAS Data Security Compliance Program </a> </h1> <div class="region region-header"> <div id="block-search-form" 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class="column"> <div class="inside"> <a id="main-content"></a> <div class="tabs"></div> <div class="region region-content"> <div id="block-system-main" class="block block-system"> <div class="content"> <div id="node-46" class="node node-webform node-promoted clearfix" about="/content/report-new-application" typeof="sioc:Item foaf:Document"> <span property="dc:title" content="Report a New Application" class="rdf-meta element-hidden"></span><span property="sioc:num_replies" content="0" datatype="xsd:integer" class="rdf-meta element-hidden"></span> <div class="content"> <noscript> <style>form.antibot { display: none !important; }</style> <div class="antibot-no-js antibot-message antibot-message-warning messages warning"> You must have JavaScript enabled to use this form. </div> </noscript> <form class="webform-client-form webform-client-form-46 antibot" action="/antibot" method="post" id="webform-client-form-46" accept-charset="UTF-8"><div><div class="form-item webform-component webform-component-textfield webform-component--application-name"> <label for="edit-submitted-application-name">Application Name: <span class="form-required" title="This field is required.">*</span></label> <input required="required" type="text" id="edit-submitted-application-name" name="submitted[application_name]" value="" size="60" maxlength="128" class="form-text required" /> </div> <div class="form-item webform-component webform-component-textfield webform-component--business-owner"> <label for="edit-submitted-business-owner">Business Owner: <span class="form-required" title="This field is required.">*</span></label> <div class="description">UCSF employee responsible for business purpose of application, typically a senior manager or faculty member.</div> <input required="required" type="text" id="edit-submitted-business-owner" name="submitted[business_owner]" value="" size="60" maxlength="128" class="form-text required" /> </div> <div class="form-item webform-component webform-component-textarea webform-component--description"> <label for="edit-submitted-description">Description: <span class="form-required" title="This field is required.">*</span></label> <div class="description">Used to describe the application</div> <div class="form-textarea-wrapper resizable"><textarea required="required" id="edit-submitted-description" name="submitted[description]" cols="60" rows="5" class="form-textarea required"></textarea></div> </div> <div class="form-item webform-component webform-component-textfield webform-component--application-owner"> <label for="edit-submitted-application-owner">Application Owner: <span class="form-required" title="This field is required.">*</span></label> <div class="description">UCSF employee responsible for routine management of application, may also perform application administrator functions, such as adding/deleting users.</div> <input required="required" type="text" id="edit-submitted-application-owner" name="submitted[application_owner]" value="" size="60" maxlength="128" class="form-text required" /> </div> <div class="form-item webform-component webform-component-textfield webform-component--application-administrator"> <label for="edit-submitted-application-administrator">Application Administrator: </label> <div class="description">Individual responsible for administration of the application.</div> <input type="text" id="edit-submitted-application-administrator" name="submitted[application_administrator]" value="" size="60" maxlength="128" class="form-text" /> </div> <div class="form-item webform-component webform-component-textfield webform-component--product-manufacturer"> <label for="edit-submitted-product-manufacturer">Product Manufacturer: </label> <div class="description">The company that makes the application.</div> <input type="text" id="edit-submitted-product-manufacturer" name="submitted[product_manufacturer]" value="" size="60" maxlength="128" class="form-text" /> </div> <div class="form-item webform-component webform-component-textfield webform-component--product-name"> <label for="edit-submitted-product-name">Product Name: </label> <div class="description">The manufacturer's name of the application (this might not be the same name used by UCSF).</div> <input type="text" id="edit-submitted-product-name" name="submitted[product_name]" value="" size="60" maxlength="128" class="form-text" /> </div> <div class="form-item webform-component webform-component-textfield webform-component--product-version"> <label for="edit-submitted-product-version">Product Version: </label> <div class="description">Version installed.</div> <input type="text" id="edit-submitted-product-version" name="submitted[product_version]" value="" size="60" maxlength="128" class="form-text" /> </div> <div class="form-item webform-component webform-component-select webform-component--category"> <label for="edit-submitted-category">Category: <span class="form-required" title="This field is required.">*</span></label> <div class="description">Business includes finance, HR, IT, etc.</div> <select required="required" id="edit-submitted-category" name="submitted[category]" class="form-select required"><option value="" selected="selected">- Select -</option><option value="business">Business</option><option value="research">Research</option><option value="education">Education</option><option value="none">None</option></select> </div> <div class="form-item webform-component webform-component-select webform-component--hosted-by"> <label for="edit-submitted-hosted-by">Hosted by: <span class="form-required" title="This field is required.">*</span></label> <div class="description">Identifies where the application is hosted. 3rd Party includes vendor, cloud, or partner institution.</div> <select required="required" id="edit-submitted-hosted-by" name="submitted[hosted_by]" class="form-select required"><option value="" selected="selected">- Select -</option><option value="ucsf_central_it">UCSF Central IT</option><option value="ucsf_department_it">UCSF Department IT</option><option value="3rd_party">3rd Party</option><option value="none">None</option></select> </div> <div class="form-item webform-component webform-component-select webform-component--number-of-users"> <label for="edit-submitted-number-of-users">Number of users: </label> <div class="description">Defines the number of people using the application.</div> <select id="edit-submitted-number-of-users" name="submitted[number_of_users]" class="form-select"><option value="" selected="selected">- None -</option><option value="1-100">1-100</option><option value="100-1,000">100-1,000</option><option value="1,000-10,0000">1,000-10,0000</option><option value="10,000+">10,000+</option></select> </div> <div class="form-item webform-component webform-component-select webform-component--number-of-phi-records"> <label for="edit-submitted-number-of-phi-records">Number of PHI Records: </label> <div class="description">Protected Health Information (PHI) is health information, paired with anything that identifies a patient (e.g., name, MRN, SSN, photo, phone number, address). The 18 personal identifiers (defined by HIPAA) are listed on https://it.ucsf.edu/policies/18-protected-health-information-identifiers.</div> <select id="edit-submitted-number-of-phi-records" name="submitted[number_of_phi_records]" class="form-select"><option value="" selected="selected">- None -</option><option value="1-499">1-499</option><option value="500-1000">500-1,000</option><option value="1001-10000">1,001-10,000</option><option value="10001-100000">10,001-100,000</option><option value="100000+">100,000+</option></select> </div> <div class="form-item webform-component webform-component-select webform-component--number-of-pii-records"> <label for="edit-submitted-number-of-pii-records">Number of PII Records: </label> <div class="description">Personally Identifiable Information (PII) is an individual's first name or first initial and last name in combination with any one or more of the following data elements: 1) Social security number, 2) Driver's license number or California Identification Card number, 3) Account number, credit or debit card number, in combination with any required security code, access code, or password that would permit access to an individual's financial account, 4) Medical information, 5) Health insurance information, 6) Email address.</div> <select id="edit-submitted-number-of-pii-records" name="submitted[number_of_pii_records]" class="form-select"><option value="" selected="selected">- None -</option><option value="1-499">1-499</option><option value="500-1000">500-1,000</option><option value="1001-10000">1,001-10,000</option><option value="10001-100000">10,001-100,000</option><option value="100000+">100,000+</option></select> </div> <div class="form-item webform-component webform-component-select webform-component--number-of-ferpa-records"> <label for="edit-submitted-number-of-ferpa-records">Number of FERPA Records: </label> <div class="description">Student records include, but are not limited to, academic evaluations, including student examination papers, transcripts, test scores and other academic records; general counseling and advising records; disciplinary records; and financial aid records, including student loan collection records.</div> <select id="edit-submitted-number-of-ferpa-records" name="submitted[number_of_ferpa_records]" class="form-select"><option value="" selected="selected">- None -</option><option value="1-499">1-499</option><option value="500-1000">500-1,000</option><option value="1001-10000">1,001-10,000</option><option value="10001-100000">10,001-100,000</option><option value="100000+">100,000+</option></select> </div> <div class="form-item webform-component webform-component-select webform-component--number-of-pci-dss-records"> <label for="edit-submitted-number-of-pci-dss-records">Number of PCI-DSS Records: </label> <div class="description">Payment Card Industry Data Security Standard (PCI-DSS) applies to any application or infrastructure that stores, processes, or transmits Cardholder Data and/or Sensitive Authentication Data. Cardholder Data is defined as the full Primary Account Number (PAN) or the full PAN along with any of the following elements: Cardholder Name, Expiration Date, or Service Code. Sensitive Authentication Data includes: Full track data (magnetic-stripe data or equivalent on a chip), CAV2/CVC2/CVV2/CID, PINs/PIN blocks.</div> <select id="edit-submitted-number-of-pci-dss-records" name="submitted[number_of_pci_dss_records]" class="form-select"><option value="" selected="selected">- None -</option><option value="1-499">1-499</option><option value="500-1000">500-1,000</option><option value="1001-10000">1,001-10,000</option><option value="10001-100000">10,001-100,000</option><option value="100000+">100,000+</option></select> </div> <input type="hidden" name="details[sid]" /> <input type="hidden" name="details[page_num]" value="1" /> <input type="hidden" name="details[page_count]" value="1" /> <input type="hidden" name="details[finished]" value="0" /> <input type="hidden" name="form_build_id" value="form-KvlQe1COxaQaeyTUGOSAEgE53pdOBGoql06gt32PbGA" /> <input type="hidden" name="form_id" value="webform_client_form_46" /> <input type="hidden" name="antibot_key" value="" /> <input type="hidden" name="honeypot_time" value="1739914580|nuEyFhelxyVTHZTC1yQXo3bWlFR3kAYizXWf9265_m4" /> <div class="cell-textfield"><div class="form-item form-type-textfield form-item-cell"> <label for="edit-cell">Leave this field blank </label> <input autocomplete="off" type="text" id="edit-cell" name="cell" value="" size="20" maxlength="128" class="form-text" /> </div> </div><fieldset class="captcha form-wrapper"><legend><span class="fieldset-legend">CAPTCHA</span></legend><div class="fieldset-wrapper"><div class="fieldset-description">This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.</div><input type="hidden" name="captcha_sid" value="176856" /> <input type="hidden" name="captcha_token" value="7e299f43896ff6d3ba1f005f74c193f8" /> <img typeof="foaf:Image" src="/image_captcha?sid=176856&ts=1739914580" width="216" height="72" alt="Image CAPTCHA" title="Image CAPTCHA" /><div class="form-item form-type-textfield form-item-captcha-response"> <label for="edit-captcha-response">What code is in the image? <span class="form-required" title="This field is required.">*</span></label> <input type="text" id="edit-captcha-response" name="captcha_response" value="" size="15" maxlength="128" class="form-text required" /> <div class="description">Enter the characters shown in the image.</div> </div> <div class="reload-captcha-wrapper"><a href="/captcha/refresh/webform_client_form_46" class="reload-captcha">Generate a new captcha</a></div></div></fieldset> <div class="form-actions"><input class="webform-submit button-primary form-submit" type="submit" name="op" value="Submit" /></div></div></form> </div> </div> </div> </div> </div> </div> </div> <div id="sidebar" class="column"> </div> </div></div> <div id="footer"> <div class="section"> <div class="region region-footer"> <div id="block-block-6" class="block block-block"> <div class="content"> <p style="text-align:center"><a href="https://datasecurity.ucsf.edu/content/report-new-application" target="_blank"><img alt="Click this image to report your application to the FAS DSCP." height="62" src="/sites/g/files/tkssra1931/f/wysiwyg/ReportYourApptoDSCP.png" width="500" /></a></p> </div> </div> </div> <div class="footer-bottom"> <nav aria-label="Footer Navigation" class="footer--navigation"> <ul> <li><a href="https://www.ucsf.edu/accessibility-resources">Accessibility</a></li> <li><a href="https://www.ucsf.edu/website-privacy-policy">Privacy Policy</a></li> <li><a href="https://websites.ucsf.edu/website-terms-use">Terms of Use </a></li> <li><a href="https://websites.ucsf.edu/azlist">A-Z Website List</a></li> </ul> </nav> <div class="footer--copyright"> <p>© 2025 The Regents of the University of California</p> </div> </div> </div> </div> </div> </div> <script type="text/javascript"> /*<![CDATA[*/ (function() { var sz = document.createElement('script'); sz.type = 'text/javascript'; sz.async = true; sz.src = '//siteimproveanalytics.com/js/siteanalyze_8343.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(sz, s); })(); /*]]>*/ </script> </body> </html>