CSINW Employee Password Reset Request Form

CSINW does not keep record of Employee Passwords. Login credentials for CSINW information systems as this information must be individually, appropriately, and responsibly managed by staff to whom they are assigned.

CSINW takes very seriously and maintains all obligations to keep secure all information under its custody and/or control from loss, from unauthorized access, and from unauthorized disclosure. CSINW shall keep and maintain a record of security breaches involving information under its custody and/or control.

Secure services and systems require ongoing confidentiality, integrity, availability, and privacy of information.

Employees Name * First Last
Manager's Name * First Last
Last Date of Successful Login
(Leave blank if unknown or use approximate date if possible.) / MM / DD YYYY

Leave blank if unknown or use approximate date if possible
Phone * - ### - ### ####
What number can the helpdesk, IT or HR staff use to contact you to assist in resolving this issue?
Email *

This is required to verify your identity.
Date of Birth * / MM / DD YYYY
Position & Program at CSINW *
Request Password Reset for:
(check all that apply)
CSINW Domain Login RAICHA HCSI Domain Login Webmail/O365 Email Account Alayacare HRDownloads Other
Reason for Password Reset/Update:
(Check all that apply) *
I've misplaced/lost/forgot my Username I've misplaced/lost/forgot my Password My credentials, as provided, do not work/cannot login I need a Website URL/Network Location/Link to login Other
Security Breach Potential:
(Check all that apply)
My credentials could have been found by someone. (ie. Lost purse/wallet, theft) My computer/phone had a virus/keylogger/malware My computer/phone was lost/stolen Other
Additional Information/Comments
I hereby understand and agree that keeping my CSINW passwords safe and secure is part of my responsibility and obligation to keep secure and confidential any and all information to which I am authorized access, and that failure to do so may result in disciplinary action, up to and including termination. *
I agree I do not agree
I hereby understand and agree that this request will be processed by CSINW Human Resources, that HR will contact me to make arrangements for me to receive my new password, that my new password will only be released to me in-person at CSINW Central Offices, and that any request for password reset will be tracked by HR. *
I agree I do not agree