Access Request

This form is intended for requesting access for Blackbox CDC PS18_1805 for individuals invited and authorized by their respective Department of Health. Requestors will be required to review and accept a University Confidentiality Agreement and to agree to comply with certain University policies. The requestor will receive an email link to the necessary documents upon completion of this application process. 
 
SCROLL DOWN to begin the application.

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* 1. First Name

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* 2. Middle Name/Initial

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* 3. Last Name

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* 4. Name of Agency (ie, Health Department)

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* 5. Email Address (must be your government agency address)

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* 6. Date of Birth

Why do we need this information? We require your date of birth as a second identifier to ensure you are not in our network with a different NetID. (This is similar to when your pharmacist or health insurance asks your date of birth, in case searching by name only brings up more than one person.)

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* 7. Work Address

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* 8. Work Address (continued)

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* 9. City

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* 10. State

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* 11. Zip Code

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* 12. Phone

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* 13. Do you have a previous affiliation at Georgetown as faculty, staff, student, or other?

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