Application Information
Application Name:
Emory Application Owner:
Emory Application Technical Contact:
Application Support Model:
Application Administration Model:
Application Description:
Application Marketplace ID/Link:
| ServiceNow Request | Distribution Status & Date | Internal Review Status & Date | ePHI Indicator | Target User Base |
|---|---|---|---|---|
Current Issues
List current issues here. When an issue is resolved, document the resolution and date, and move the issue into the issue log.
Issue Log
Maintain a list of issues and their resolution.
Reapproval Conditions
Document the conditions under which the application would be subject to reapproval (e.g., collecting ePHI data when it did not previously).
Internal Review Status: complete or incomplete
| Internal Distribution Request Date | Compliance & Regulatory Review | IT Security Review |
|---|---|---|
Collateral
Upload collateral as it is collected.
Approval Artifacts
Upload approval artifacts as they are collected.
- Compliance and Regulatory Review.
- IT Security Review.
- Distribution Review Checklist.
Application Information
Application Name:
Application Owner:
Application Technical Contact:
Application Description:
Application Marketplace ID/Link:
Current Issues
List current issues here. When an issue is resolved, document the resolution and date, and move the issue into the issue log.
Issue Log
Maintain a list of issues and their resolution.
Reapproval Conditions
Document the conditions under which the application would be subject to reapproval (e.g., collecting ePHI data when it did not previously).
Internal Review Status: complete or incomplete
Collateral
Upload collateral as it is collected.
Approval Artifacts
Upload approval artifacts as they are collected.
- Compliance and Regulatory Review.
- IT Security Review.
- Distribution Review Checklist.