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COMMONWEALTH OF VIRGINIA VDSS DISASTER PROFILE/REMOTE ACCESS REQUEST FORM DISASTER SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM The following information will be used to grant remote access or an additional EBT Issuance Profile for the Disaster System. You must fax the completed form to the Security Unit at Home Office: Fax # 804-726- 7891. Incomplete forms will be returned. Note: This access will be removed after the disaster period ends.

Existing VA EBT User ID

Existing User Profile #

User’s Full Name:

Position/Title:

Phone # with area code

Agency/Division

FIPS:

Access Authorization:

Does this user require remote access to the VDSS Disaster System? Yes NO

Does this user require EBT Issuance Profile 06 to the VDSS Disaster System? Yes NO

Acknowledgment:

Inappropriate access to or use of Disaster System and or computer application/systems is a violation of the Department’s Security Policy and may result in the Department initiating administrative and/or criminal action against the responsible party. By signing I acknowledge that the password and other access devices are my responsibility to safeguard.

User Signature

Date:

Approval:

Supervisor’s Signature

Date:

Director/Designee’s Signature

Date:

(Information Security Unit Use Only)

EBT Disaster Profile assigned:

Initial Password:

Remote Access User ID:

Initial Password:

EBT Unit Signature / Date:

Info Security Signature / Date:

If you have questions regarding your User ID, contact the Information Security Unit at security@dss.virginia.gov

Form retained by Information Security Unit for 5 years Created 08/08/05 rev: 10/01/09