Department Name:	System Member:
Camera Location: Bldg. Name:	Request Date:
Building Number:	Desired Installation Date:
Primary Contact Name:	Email:
Phone Number:

Purpose of Surveillance Equipment:
Describe specific reasons for installation. If this request is based on a concern for safety or theft, please indicate whether the concern is based on potential incidents that might occur or actual events that have occurred previously. (Attach document if needed.)

Installation Details:

Installation Life/Location:

Temporary, End Date _________

Permanent	Operation Hours:

24x7

After hours

Other, please specify _______	Recording:

Not Recorded

Recorded
Real Time (live) Monitoring:

Not monitored

Continuously Monitored

Periodically Monitored

If continuously or periodically monitored, is the viewing/monitoring area secure from unauthorized observers?

Monitoring Schedule (only if monitored in real time):

Camera Features: (Check all that apply)	Camera Connection:

Pan

Wired
Tilt

):___________ ____________________	Wireless
Zoom

Fixed

Other (please specify):_______________________________________________________________

Comments:

Site Plan:

Please attach a floor plan showing the location and field of view for each camera in the request.

Total number of cameras in the building:
Total number of cameras per floor (multi-floor facilities):
Please list room numbers and/or a location description (e.g., NW stairwell 2nd floor, SE entrance, etc.) for each camera.

Security Plans:

Server Security Plan:

Server Location:	Building Name:
Building Number:
Non-TAMUS Building, provide address:

Security Plans Continued:

Server Security Plan:

How is physical access to server secured: (Card reader, key lock, etc.)?

Type of Access: How is access to the data controlled: (Log-ins/ Password Protected, etc.). Is access to the data (recorded material) logged?

Appropriate Use and Training

I certify that all persons having direct access to AVST data that is stored and/or managed by my department will:

___	Complete the Audio Visual Surveillance Technology (AVST) Operations Training (TrainTraq course # 2111557) as specified in the AVST Operational Standards & Guidelines and sign/acknowledge the AVST Ethics Statement (contained within the training).

I understand that if the training requirements are not met, prior approvals for installation/activation of surveillance equipment may be revoked by the AVST committee.

______________________________ ______________ ___________________________ __________

Resource Owner - Printed Name	Title	Signature	Date

(Must be Director, Dean or Department Head)

Texas A&M Information Technology
Audio Visual Surveillance Technology Committee

Audio Visual Surveillance Technology Installation/Activation Request

Page 2 of 3	In accordance with Texas A&M’s Standard Administrative 29.01.99.M1.28 Procedure Information Resources – Security Surveillance (http://rules-saps.tamu.edu/PDFs/29.01.99.M1.28.pdf). Submit this form with the site plan and any documents you have regarding procedures and controls to avst@tamu.edu to request installation approval for surveillance equipment (e.g., video cameras). (Version 130825)

Michelle R Osterholm

2013-08-26

Jeffrey C McCabe

TAMU