information security exemption request confidential · 2020. 12. 22. · 1. provide background...
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STATE OF CALIFORNIA – DEPARTMENT OF GENERAL SERVICES INFORMATION SECURITY EXEMPTION REQUESTInformation Security Office - Form ISO-04
REQUESTER INFORMATION
DGS-ISO USE ONLY
Date Information Security Officer or Designee Signature / Printed Name
Department of General Services Information Security Exemption Request
ISO-04 - Ver. Jan2020 Page 1 of 1
DGS Information Security Office(916) 376-3940 or [email protected]
3. Phone Number:
5. Office/Unit:
EXEMPTION INFORMATION
REQUESTER SIGNATURE Date Signature
Please address the following information with details about the information security exemption being requested and be as detailed as possible. Upon completion, please print and sign this document and send to the Information Security Office: 707 3rd Street, 3rd Floor, West Sacramento, CA 95605. Alternatively, this form may also be printed, signed, scanned and emailed to [email protected]. Please note: This request must first be approved by the ISO prior to the implementation of this exemption. Please do not email this form directly to the Chief Information Security Officer or directly to individual Information Security staff.
1. Provide background information for this request. Cite current DGS policies/procedures that need to be circumvented for this request.
2. Identify alternatives considered and explain why said alternatives are determined not to be an appropriate course of action.
3. Explain how this exemption will solve or mitigate the current situation detailed above and include how long the exemption is needed.
4. Describe the risks involved in the implementation of this exemption. Must not be left blank or "N/A".
5. For the risks identified, please describe the action(s) which will be taken to mitigate these risks. Must not be left blank or "N/A".
☐ APPROVED ☐ APPROVED WITH CONDITIONS ☐ DENIEDISO Comments:
1. Requester Name: 2. Job Title:
4. Division:
6. Short Description of Exemption Request:
CONFIDENTIAL
APPROVING MANAGER, OFFICE CHIEF OR DEPUTY DIRECTORDate Signature and PRINTED NAME
Expiration / ISO Review Date:
Tracking ID#:(ISO Use Only) ______________