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Instructions for LSI Security Change Request Form (OTM-30)(08/07) The LSI Security Change Request Form should be completed by the agency-authorized firewall change request authority. Sections 1–12 at the top of the page should be completed by the agency requesting modifications to the LSI firewall. 1. Requester's Name (Printed): Enter the name of the person making the firewall change request. 2. Requester's Phone #: Enter the phone number of the contact person for the request. 3. Requester's Email: Enter the email address of the contact person for the request. 4. Department: Enter the department name of the person making the request. 5. Division: Enter the division name of person making the request. 6. Change Category: Mark the change category. A normal change request will be handled within two working days. An emergency change request will be handled as quickly as possible. To be an emergency the change must correct a major security risk. 7. Proposed Change Date: Enter the date changes to the firewall should be applied. If changes do not need to be applied on a specific day leave this field blank. 8. Requested Changes: Enter the requested firewall rule modification information. The source address, source port and protocol, destination address, destination port and protocol, action, add/remove rule, and reason for change must be completed for each change requested. An example is provided on the form. If necessary, indicate additional requests on a blank page and attach to the form. 9. Request/Remove Static Address Under Private IP Address, enter private addresses to be Assignment for: translated to public addresses if needed (static translation). Leave Translated to Public Address blank. OTM will assign public addresses. 10. Description of What You are Enter a brief description of what is to be accomplished with the Trying to Accomplish: firewall rule change. If necessary, attach additional pages. 11. Authorized Requester's Enter the signature and job title of an authorized agency Signature, Title: contact. If the form is submitted by email a signature is not required, but the email must originate from an authorized agency contact’s email address. 12. Date: Enter the date of signature. The bottom sections of the form will be completed by LSI staff. The form can be faxed to 225-219-4867 or emailed to OTM-LSI-Security@listserv.doa.la.gov. Confirmation of the completion of the requested change will be made to the requester by phone or email.