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Part 8, Chapter 17: Manual Exhibit 8-17-A

Mobile Device
Justification and User Agreement

The Indian Health Service (IHS) is responsible for issuing and managing IHS-issued mobile devices and their associated service plans.  This form must be completed before a Federal employee or Contractor is authorized to receive an Agency-issued mobile device.

This form must also be completed and signed (by the user and the first and second level supervisors) and provided to the first line supervisor and designated IHS Ordering Official.  Failure to do so will result in the deactivation of the mobile device.


  1. Complete this form; sign and date it before requesting an Agency-issued mobile device.
  2. Submit this form to your first level supervisor.

The first level supervisor will retain the original signed copy of the "Mobile Device Justification and User Agreement," in the employee's personal administrative file as long as the user retains the device.

PART 1 - Account Holder Identification

Name of Person Receiving Property:
Office Phone: (_______________________)

PART 2 - Requirement/Justification/Approval

Request is for:  (please check appropriate device)

Cell Phone___ Smartphone____ Tablet____

Justification (including the business need for the request):_________________________________________________________

Approved____ Disapproved____

First Level Supervisor:___________________________________ Date:_________________

Approved____ Disapproved____

Second Level Supervisor:__________________________________ Date:_________________

PART 3 - Service Agreement (Please initial each statement and sign at the bottom)

___I agree to follow all local, State, and Federal laws regarding the use of an IHS-issued mobile electronic device.

___I understand that I may be required to reimburse the IHS for any service charges not authorized per this agreement, and/or deemed to be personal use that exceeds permitted usage as defined in Part 8, Chapter 17, "Agency-Issued Mobile Devices Including Cellular Telephones, Smartphones, and Tablets," Indian Health Manual.

___I understand that Agency issued mobile devices are not approved for handling sensitive information unless properly encrypted and that I must exercise discretion when using an IHS-issued mobile device.

___There shall be no expectation of privacy when using an IHS-issued mobile device including Pin-to-Pin messaging, Short Message Services (SMS), or Multimedia Messaging Services (MMS) messaging.  All logs, data, and other files created while using an IHS-issued mobile device are neither private nor confidential.

___I understand that usage of an IHS-issued mobile device is subject to all conditions in Part 8, Chapter 17, IHM.

___I agree that I will not display any IHS-issued mobile device passwords in public or attach passwords to any device.

___I understand that I must secure my IHS-issued mobile device to ensure that it is not lost or stolen.

___I understand that I must contact the IHS ISSO or the Area ISSO immediately if my IHS-issued mobile device is lost or stolen.  If immediate contact is not possible, I must contact the IHS OIT Help Desk (888-830-7280) within 24 hours of the reported loss.

___I understand that after 6 failed login attempts, all data on my IHS-issued mobile device will be erased automatically and that the device will revert to the manufacturer's default state.  I will contact the IHS OIT Help desk to arrange to have my mobile device reconfigured.

___I understand that I am responsible for following any additional security regulations concerning my IHS-issued mobile device as defined in Part 8, Chapter 17, IHM, and the IHS Rules of Behavior.

___I understand that I will not install or download any software, application, or program not issued by the IHS unless I have received prior approval from the Ordering Official and my IT Security office.

User's Signature:______________________________________ Date:_________________________