To be used in lieu of
VA FORM 2105
Date:
From:
Subj: Authorization to Transport and Utilize VA Sensitive Information Outside Protected Environments
To: VAMHCS Information Security Officer (512/BT/ISO)
Thru:
1. In order to accomplish my duties, I require the capability to store, transport and/or utilize
VA sensitive information outside protected environments, as defined by VA Directive and
Handbook 6500. VA information refers to all information, either electronic or paper-based.
My personal information follows:
Requestor’s Full Name: Title:
Home Address: City:
State: Zip Code: Home Phone:
2. Justi
fi
cation for the removal of VA sensitive information outside of protected environments
(include where and how information will be used):
3. The sensitive information, as defined in VA Directive and Handbook 6500, I intend to
transport and utilize includes (check all that apply):
4. In what medium does the information reside? (electronic, CD, paper, etc…)
Department of
Veterans Affairs
Memorandum
Individually identifiable medical, benefits, or personnel information
Information that can be withheld under the Freedom of Information Act
Information that is confidential or privileged in litigation
Information that could adversely affect national interest or federal programs
Investigatory Information
Law Enforcement Information
Other:____________________