To complete the Data Security/Confidentiality Individual Application you are
required to have a State of Ohio user account.
To create your State of Ohio user account click on this link https://ohid.ohio.gov
If you need assistance or have questions on the Data Security/Confidentiality
Individual Application please contact us at 1-800-617-6733 Option 4.

---

What's This	Account Type :	---------------- State Employee Independent or Agency Provider Medication Administration Nurse or Secretary School District Employee County Board or COG Employee Advocacy and Protective Services Inc.(APSI) Licensure Designee *
What's This	Request Type :	---------------- Renew Account Add System Access Change System Access Terminate User Account *

---

First Name:	*     MI:     Last Name: *
Phone Number:	* ex.(###)###-####      invalid phone number
Email Address:	* invalid email
*	I certify that the listed email is my personal email address and not a group or shared email.

---

		*
		*
		*