MSIX User Access Form with Privacy Axt

User Application for Access to MSIX

STEP 1: Applicant Information

• The Applicant completes the Applicant Information and signs the form.

• The Applicant forwards the form to a Verifying Authority. This should be the Applicant’s direct supervisor or an individual that is above the direct supervisor in an official reporting structure. The Applicant must provide appropriate identification (such as state/district identification badge, passport, driver’s license, etc.) to verify their identity.

STEP 2: Identification Verification and Attestation

• The Verifying Authority completes his/her own information, reviews the entire application for completeness and accuracy, confirms the Applicant’s identification, attests to the Applicant’s need of an MSIX account, and confirms the right level of access.

• Upon completion, the Verifying Authority returns the form to the Applicant.

STEP 3: Forward Form to Approving Authority

• The Applicant locates his/her State/Regional Authority for final approval by going to the MSIX website: https://msix.ed.gov.

• The Applicant clicks on the link labeled ”How Do I Get An Account?” to access the contact information for their state.

• The Applicant forwards the form to the State/Regional Authority for final approval.

STEP 4: State/Regional Authority Approval

• The State/Regional Authority reviews the Applicant and Verifying Authority portions of the application for completeness, completes his/her own information, signs the form, and files it in his/her local records.

• The State/Regional Authority creates an MSIX account for the Applicant.

• The Applicant receives two emails: one with his/her MSIX User Name and the other with his/her initial Password.

Applicant - Instructions to the Applicant

Applicant Information Complete the applicant information below and sign the form. Forward the form to a Verifying Authority. This should be your direct supervisor or an individual that is above the direct supervisor in an official reporting structure. Provide appropriate identification information.
First Name				Last Name
Title
Work Address	Street		City						State	Zip
Work Email					Work Telephone			XXX-XXX-XXXX   Ext.
Region (if applicable)					School District (if applicable)
MSIX Account Information
MSIX Role(s)	MSIX Primary User MSIX Secondary User	Regional User Administrator State User Administrator				District Data Administrator Regional Data Administrator State Data Administrator					State Region Administrator
Signature
I certify that this information is accurate and complete to the best of my knowledge. I will only use MSIX in accordance with the MSIX Rules of Behavior. Signature: _________________________________________________ Date: ______________________

The Privacy Act of 1974 (5 U.S.C. § 552a)

Verifying Authority - Instructions to the Verifying Authority

Identification Verification and Attestation As the Verifying Authority, you should be the Applicant’s direct supervisor or an individual that is above the direct supervisor in an official reporting structure. Review the entire application for completeness and accuracy. Complete the information below, confirm the Applicant’s identification, attest to his/her need of an MSIX account, and confirm that the Applicant has the right level of access. Upon completion, file the form in your local records and return this form to the Applicant.
Verifying Authority First Name			Verifying Authority Last Name
Title
Work Email		Work Telephone		XXX-XXX-XXXX   Ext.
Organization		Applicant Identity Verification Method		State Driver’s License State / District ID Passport Other: ________________
Account Effective Date (optional)		Account End Date (optional)
Signature
I certify that: 1) I have verified the identity of the above applicant; 2) I have determined that he or she has a need for MSIX information; and 3) the above-mentioned individual is requesting the appropriate MSIX role(s). Signature: _________________________________________________ Date: ______________________

Final Approving Authority - Instructions to the Final Approving Authority

State/Regional Authority Approval Review the Applicant and Verifying Authority portions of the application for completeness. Complete the information below, sign, and file the form in your local records. Create an MSIX account for the Applicant.
Approving Authority First Name		Approving Authority Last Name
Title				Role	Regional User Administrator State User Administrator
Work Address	Street	City				State	Zip
Work Email			Work Telephone		XXX-XXX-XXXX   Ext.
Signature
I certify that this information is accurate and complete to the best of my knowledge and I hereby grant to the above-mentioned individual the MSIX role for which they have applied. Signature: _________________________________________________ Date: ______________________

The Privacy Act of 1974 (5 U.S.C. § 552a)

Privacy Act Statement

The Department of Education (Department) will use the information that you provide on the attached MSIX User Application Form to promote secure and appropriate access to the Migrant Student Information Exchange (MSIX) system. The Department owns the MSIX system, including the data stored therein, which has a significant value and is an integral part of the infrastructure that supports the Department’s mission, goals and critical operations. It is essential that information in the MSIX system is properly secured and protected against information security related threats and dangers. MSIX has incorporated access controls to protect it against inappropriate or undesired user access. The process of granting and controlling access begins with the completion of the MSIX User Application Form, and the granting of rights and privileges. The MSIX User Application Form serves an integral part of the Department’s system to identify and verify authorized users for access to MSIX, assign roles to authorized users of MSIX, tie actions taken within MSIX to a specific user, control access to MSIX and ensure authorized users only have access to MSIX that is needed to perform the actions required by their positions, prevent the inappropriate release of information in MSIX, and document that MSIX users understand the MSIX rules of behavior.

The Department requests the information on the attached Form under the authority provided by section 1308(b)(2) of the Elementary and Secondary Education Act (ESEA), as amended by the No Child Left Behind Act of 2001 (20 U.S.C. Section 6398(b)(2)). Your disclosure of information is voluntary, but if you do not submit the requested information, either on this form or, in a State form, if applicable, that requests that you provide the same information, then you will not be granted access to use the MSIX system.

Without your consent, the Department may disclose information provided to entities under a published "routine use." Under such a routine use, we may disclose information to a third party contractor that we have hired to perform any function that requires disclosure of records in this system to employees of the contractor; to a researcher if an appropriate official of the Department determines that the individual or organization to which the disclosure would be made is qualified to carry out specific research related to functions or purposes of the MSIX system; to the U.S. Department of Justice (DOJ) or the Office of Management and Budget (OMB) if the Department concludes that disclosure is desirable or necessary to determine whether particular records are required to be disclosed under Freedom of Information Act or the Privacy Act; or to appropriate agencies, entities, and persons when (a) it is suspected or confirmed that the security or confidentiality of information in MSIX User Application Form has been compromised; (b) the Department has determined that as a result of the suspected or confirmed compromise, there is a risk of harm to economic or property interests, identity theft or fraud, or harm to the security or integrity of MSIX User Application Form or other systems or programs (whether maintained by the Department or by another agency or entity) that rely upon the compromised information; and, (c) the disclosure is made to such agencies, entities, and persons who are reasonably necessary to assist the Department in responding to the suspected or confirmed compromise and in helping the Department prevent, minimize, or remedy such harm.

If the federal government, the Department, or an employee of the Department is involved in litigation or alternative dispute resolution (ADR), we may send your information to the Department of Justice, a court or adjudicative body, or parties, counsel, representatives and witnesses, if the disclosure is relevant and necessary to the litigation or ADR. We may disclose your information to a member of Congress if you have asked for their assistance in addressing an issue related to your access to the MSIX. In addition, we may send your information to a foreign, federal, state, or local enforcement agency responsible for enforcing, investigating, or prosecuting violations of administrative, civil, or criminal law or regulation if your information is relevant to any enforcement, regulatory, investigative, or prosecutorial responsibility within the receiving entity’s jurisdiction. In the event that the information that you submit, alone or in connection with other information, indicates a violation or potential violation of any applicable statute, regulation, or order of a competent authority, the Department may disclose your information to the agency that has the responsibility for investigating or prosecuting the violation or enforcing or implementing the statute, regulation, or order. Finally, we may disclose your records to the DOJ to the extent necessary for obtaining DOJ advice on any matter relevant to an audit, inspection, or other inquiry related to the Migrant Education Program.

Public Burden Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. Public reporting burden for this collection of information is estimated to average 20 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is required to obtain or retain benefit under P.L. 107-110, Section 1308b, Elementary and Secondary Education Act (as amended) by the No Child Left Behind Act. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Education, 400 Maryland Ave., SW, Washington, DC 20202-4536 or email [email protected] and reference the OMB Control Number XXXX-XXXX. Note: Please do not return the completed MSIX Application to this address.

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