Blackbox CDC PS18_1805 Access Application

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.

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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.)

Date

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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?

Yes