The form your staff complete to request approval of a new AI tool or a new use case for an already-approved tool. Submit to the AI Use Officer at least ten business days before intended first use. The completed Worksheet, with the AI Use Officer’s signature, becomes the approval record kept under Section 11 of the Staff Handbook. Last reviewed: May 25, 2026.

Part 1: Requester Information

• Requester name:
• Role / department:
• Date submitted:
• Intended first-use date:

Part 2: Tool Information

• Tool name:
• Vendor:
• Plan / tier:
• Total cost (monthly / annual):
• Billing frequency:
• Vendor Evaluation Checklist attached? (Y/N) — see Vendor Evaluation Checklist.
• Vendor agreement attached (MSA, DPA, BAA, as applicable)? (Y/N)
• Is this a new tool, or a new use case for an existing approved tool?

Part 3: Use Case

• Describe the specific use case in two or three sentences. What task will the tool support? Who will use it?
• Estimated frequency of use (per day, per week):
• Estimated number of staff using the tool:
• Specific program(s) or organizational function(s) this supports:
• If charged to a federal award: which award, and what funded activity does this support?
• What is the alternative if this is not approved? (Continue current process / use a different tool / drop the activity.)

Part 4: Data Class Assessment

Identify the highest data class the tool will process. Definitions in Staff Handbook §3.

• [ ] Public
• [ ] Internal
• [ ] Confidential
• [ ] Sensitive / Regulated

If Sensitive / Regulated, identify the regulatory basis (HIPAA, FERPA, state child-welfare law, contract-protected, attorney-client, federal award data-use terms, other):

Part 5: Risk Assessment

• Identify the worst plausible outcome if this tool fails or is misused (e.g., wrong information reaches a participant, sensitive data exposed, funder reporting error, regulatory violation).
• What human-review step will catch errors before they reach an external recipient?
• What logging or documentation will exist for this use? Where will it be stored?
• What is the disclosure tier under §7 of the Staff Handbook? (Silent / Footer / Explicit). Rationale:
• What is the rollback plan if this tool stops working or is sunset by the vendor?

Part 6: Tier Assignment

Based on Parts 3–5, the requester proposes this tier (see Staff Handbook §4):

• [ ] Permitted (no further approval needed beyond the Approved-Tool List entry)
• [ ] Restricted (this Worksheet serves as the approval record)
• [ ] Prohibited under §8 of the Staff Handbook (do not submit)

Part 7: Federal-Award Considerations

Complete this section only if any portion of this tool’s cost will be charged to a federal award, or if the tool will be integrated into federally funded program activity.

• Award name and federal awarding agency:
• Award period and remaining balance:
• Is this cost in the approved budget? (Y/N) If no, what budget modification or written approval will be obtained, and when?
• Cost classification: [ ] Direct [ ] Indirect [ ] Shared (allocated)
• If shared: describe the allocation methodology and where it is documented. (Per 2 CFR 200.405.)
• Performance reporting impact: will this tool affect how outputs are produced or reported? If yes, how will that be reflected per 2 CFR 200.329?
• Has the relevant grants officer been informed in writing? (Y/N — attach correspondence if yes.)

See Federal Grants & AI Compliance Quick Reference for guidance.

Part 8: AI Use Officer Decision

To be completed by the AI Use Officer.

• Decision: [ ] Approved [ ] Approved with conditions [ ] Denied
• Conditions or scope of approval (data classes, use cases, retention, disclosure tier):
• Effective date:
• Expiration date (default 12 months from effective date):
• Rationale (especially for denials or conditions):
• Approved-Tool List entry created / updated? (Y/N)

AI Use Officer signature: __________________________________ Date: __________

Renewal

This approval expires on the date in Part 8. To renew, the requester submits a brief addendum confirming: no change in use case, no change in data class, no change in vendor terms, no incidents in the prior 12 months. If any of those have changed, complete a new Worksheet.

Used together with the Vendor Evaluation Checklist and the Staff Handbook. Templates only — not legal advice.