Fillable BYOD Device Registration Form

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BYOD Device Registration Form

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The BYOD Device Registration Form form is 3 pages long and contains:

  • 1 signature
  • 18 check-boxes
  • 11 other fields

Country of origin: OTHERS
File type: PDF

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BYOD Device Registration Form copyright of Person Centered Tech.
BYOD Device Registration Form
G R O U P P R A C T I C E
Device Owner Name:
Date:
Device Description:
I will be using this personal device within my work duties and my device may or may not
come into contact with PHI and be a source for safety and security issues regarding our
clients. To mitigate unethical or unsecure behavior, I am registering my device and making
sure it meets the security standards set by
[practice name]
An audit of the device’s security measures has been performed and is documented below.
Auditor:
Name of auditor:
Primary Intended Use*:
*e.g. such as accessing practice services (i.e. email, practice management system, e-fax, VoIP
app, etc.,) or performing practice functions (i.e. calling or texting with clients, taking photos of
insurance cards/client info, creating and/or storing documentation/records.)
Operating Software
Version:
Yes NoMost Recent Version?
T E C H N I C A L M E A S U R E S
If the technical measure is not applicable to your device, check N/A:
Encrypted (full device)
N/A
Antivirus Active
N/A
Firewall Active
Password is strong
N/A
N/A
Set to log out after idle time
N/A
Tracking software is active
N/A
N/A
Has a user account just for doing
[practice name]
business.
Backup Strategy For This
Device (or explain why it’s
not needed):
BYOD Device Registration Form copyright of Person Centered Tech.
The device, as described above, currently satisfies the requirements of
[practice name]
policies and procedures, including the Bring Your Own Device Policy:
Yes No
BYOD Device Registration Form copyright of Person Centered Tech.
If, at a later date, this device will no longer be used in a clinical setting, this
device will need to be properly retired from use. This retirement process
may include properly removing and verifying that no sensitive information
still is held in the device.
I agree to comply with the policies and procedures of:
[practice name]
with regards to this device, including the Bring Your Own Device Policy.
I have read the Bring Your Own Device Policy and understand its contents.
Signature of Device
Owner:
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signature
click to edit
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BYOD Device Registration Form

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Completed 26 August 2021

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