User Access Recertification Checklist Form
Review and confirm whether users should retain access to systems. Please complete all required fields for each user under review.
User Full Name
*
First Name
Last Name
Department or Team
*
System(s) or Application(s) Accessed
*
Current Access Status
*
Please Select
Active
Inactive
Suspended
Access Review Decision
*
Retain Access
Revoke Access
Justification for Decision
*
Reviewer Full Name
*
First Name
Last Name
Review Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Recertification
Should be Empty: