Healthcare / Public Health RegistrationWho should subscribe? Partners with a "right" and "need-to-know" Sensitive public safety information who are currently employed in a public health role, such Infectious and Commonable Diseases, Food & Water Safety, Emergency Medical Services, Hazardous Material Management and government hospitals; have attended a Terrorism Liaison Officer (TLO) course (or ILO Basic Training Course via InfraGard). Subscription email must be agency-affiliated. No group or personal email addresses. Please contact firstname.lastname@example.org with any questions.
APPLICANT * REQUIREDFirst Name *Last Name *Position/Title/Rank *Phone Work *Mobile PhoneYour Agency Email Address * (No personal email address)Retype your e-mail address *CURRENT ASSIGNMENT *
Describe Your Current Duties, Role and Responsibilities * POST ID# (Law Enforcement Only)
If you do not have this number, please contact your Agency's Training Coordinator.DISCIPLINE / AGENCY TYPE *Law EnforcementFederalMilitary TribalHealthFireEMSPrivate SectorCorrections/Probation/ParolePublic EducationOtherIf Other specify below:PROFILE / ACCOUNT ACCESSPassword *Create a password to access your account
AGENCY/ORGANIZATION NAME *Select your agency name belowIf your agency does not appear above, click "-Other-", then enter your Agency Name below. (no abbreviations)Other Agency/Organization NameAGENCY ADDRESSAddress 1 *Address 2City *County *- Select County -Los AngelesOrangeRiversideSan Luis ObispoSanta BarbaraSan BernardinoVenturaOther
State *Zip code *SUPERVISOR INFORMATIONSupervisor Full Name * Supervisor Phone * Supervisor Email Address *
Non-Disclosure Terms and Conditions Agreement between the Joint Regional Intelligence Center (JRIC) and the Subscriber/Registrant
I attest that, in protecting the information provided, I will ensure that the information:
I agree that I will not disclose or release any information provided to me by the JRIC pursuant to this Agreement without proper authorization from the JRIC. Should situations arise that warrant the disclosure or release of information provided I will do so only under JRIC approved circumstances and in accordance with the laws, regulations, or directives applicable to the specific categories of information.
I agree that I will promptly report to the appropriate official any loss, theft, misuse, misplacement, unauthorized disclosure, or any other security violation of which I have knowledge.
I understand my responsibilities and am familiar with and will comply with the standards for protecting such information that I may have access to in accordance with the terms of this Agreement and the laws, regulations, and/or directives applicable to the specific categories of information to which I am granted access. I understand that audits may be conducted at any time for the purpose of ensuring compliance with the conditions for access, handling and safeguarding information under this Agreement and in compliance with 28 CFR guidelines.
I acknowledge that if I violate any of the terms or conditions of this Agreement, such violation may result in the notification of my home agency and the cancellation of my access to the information covered by this Agreement.
Please sign and date this agreement
Signature *Date Signed