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Form NameForm Col
Form Length4 pages
Fillable fields38
Avg. time to fill out8 min 40 sec
Other nameswhich tax form for college tuition, warning violation form, what is colorado form 104, color of law form

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U. S. Coast Guard CG-7421G (Rev. 10/20)



1. User’s Name (Last, First, MI.) (Please print or type)


2. Rank/Rate:

3. Employee ID #





4. Dept ID & Unit Name (Include Staff Symbol)

5. Area Code & Phone Number:

6. e-Mail address:





7. User Role Description:


WIMS User Access Approval:


Family Advocacy Specialist


Please see “How to complete and route the User Access Form (CG-7421G)


at for



Family Advocacy Program Manager


the approval process and listing of authorized approvers

Family Resource Specialist


Direct Access User Roles:


Special Needs Program Manager




Direct Access user roles and access are administered separately. Please

Substance Abuse CDAR



complete form CG-7421G for changes/additions to Direct Access user roles.

Substance Abuse SAP





Substance Abuse Program Manager



Sexual Assault Specialist


Direct Access Roles are automatically terminated upon PCS, separation,


retirement, reassignment of duties (Fleet-Ups) and change of organization

Sexual Assault Program Manager


(inter-office transfer).


Critical Incident Stress Management Specialist (CISM)

Users who have been reassigned (PCS, Change of Department IDs) will



CISM Program Manager


retain Self-Service access.


Employee Assistance Specialist


The user role termination process is kicked off by submission of a PCS

Employee Assistance Program Manager



departing endorsement. If the member submits a new access form, and it is

Workplace Violence & Threatening Behavior Specialist

processed by PPC before the SPO submits the PCS departing

endorsement, the system will terminate the new access. Please be sure to

Workplace Violence & Threatening Behavior Program Manager

submit transactions in a timely manner.

Victim Witness Specialist


If Revocation is due to reasons other than those listed above contact PPC

Victim Witness Program Manager



Customer Care via on-line trouble-ticket at

__________________________(Other Role, not listed above)

or or via



email at

8. Authorizing Official (Signature & Typed or printed name, Rank, Title (HSWL Product-Line Manager (PLM) (Field Office Supervisor)) & Phone


I certify that the access I have authorized is based on an official need. I'm aware of the general functionality I have authorized and I'm aware of what this will allow this member to complete. If this is for a contractor, the Contracting Officer’s Technical Representative (COTR) signs as AO.


Signature AND PRINTED or TYPED Name,



8a. Area Code & Phone (ext):


9. Date:

10.Approving Official (Signature & Typed or printed name, Rank, Title ( Work-life Division Chief/Deputy):

I certify that the access I have authorized is based on an official need. I'm aware of the general functionality I have authorized and I'm aware of what this will allow this member to complete. If this is for a contractor, the Contracting Officer’s Technical Representative (COTR) signs as AO.


Signature AND PRINTED or TYPED Name,



10a. Area Code & Phone (ext):


11. Date:







Privacy Act Statement


Executive Order 10450, 9397; and Public Law 99-474, the Computer Fraud and Abuse Act.

PRINCIPAL PURPOSE: To record names, signatures, and other identifiers for the purpose of identifying individuals requesting access to U. S.


Coast Guard (USCG) systems and information. NOTE: Records may be maintained in both electronic and/or paper form.



Disclosure of this information is voluntary; however, failure to provide the requested information may impede, delay or


prevent further processing of this request.

Acknowledgment: I understand that I am authorized to access the Direct Access system and that accessing it for purposes beyond the Scope of

Authorization is a violation of Federal law (18 U.S.C. 1030 et al) (Note: Refer to the Automated Information Systems (AIS) User Acknowledgement Form (CG-5500A), which is required for all U.S. Coast Guard AIS users, it contains the full Scope of Authorization and Acknowledgement.)

12. User's Signature:

13. Date:


Email form to: PPC-DG-

(only send page 1, do not send instructions)

CG-7421G (Rev. Oct 2020) (Reverse)

Please refer to “How to complete and route the User Access Form (CG-7421G) at for additional/updated information.

Block Instructions

1Enter the user’s last name, first name and middle initial.

2Enter the user’s Rank (e.g. “CAPT”) or Rate (e. g. “YN1”) or GS paygrade (e. g. “GS7”)

3Enter the user’s employee number. The employee ID number can be found on the unit roster. Any member of the command that already has access to Direct-Access can access the unit roster and locate the employee’s employee ID number. Follow these steps to access the unit roster:

Select the following links on the Portal home page: Human Resources > Human Resources Reports > CG Unit Roster Report.

Follow the procedure guide at to run the report.

4Enter the name of the unit the user is assigned, include the staff symbol if applicable.

5Enter the user’s business phone number, including the area code.

6Enter the user’s business e-mail address.

7Choose the appropriate user role from the list provided.

8Enter the Name, Rank, Title, and Phone number of the authorizing official (HSWL Regional Manager (RM) or Work-Life Supervisor).

9Enter the date the form was signed by the authorizing official.

10Enter the Name, Rank, Title and Phone number of the approving official. ( HSWL SC designated representative - Please see “How to complete and route the User Access Form (CG-7421G) at for additional/updated information).

11Enter the date the form was signed by the approving official.

12User signs here.

13Enter the date the form was signed by the user.

CG-7421G (Rev. 10.20) (Reverse)


Work-Life Information Management System (WIMS)

Work-Life Program

Phone Number

Family Advocacy


Special Needs


Substance Abuse


Sexual Assault


Critical Incident Stress Mgmt

202 475-5156

Employee Assistance

202 475-5156

Workplace Violence & Threatening Behavior

202 475-5156

Victim Witness

202 475-5156

Note: In the event that HSWL SC designated representative is not available for signature you may contact Program at the above listed numbers for signature.

Who is authorized access?

Only Coast Guard personnel assigned duties in one of the 8 respective areas identified above can be granted access to the system.

How to complete the Direct Access Work-Life Management System User Account Authorization (CG-7421G)?

The individual requiring access completes blocks 1 through 7, and signs in block 12. The HSWL Regional Manager (RM) or Work-Life Supervisor will complete block 8. Then pages 1 and 2 of CG-7421G will be sent electronically or scanned via email to the HSWL SC designated representative.

The HSWL SC designated representative will review and approve access and then submit the signed form to PPC Topeka.

PPC Topeka will then grant user access to the system.

Direct Access II Functional Roles on CG-7421G

User access to the system and approval of the Functional Roles within WIMS lies with the Regional Program Manager and HSWL SC Work-Life Division staff. For example, if you were assigned as the Family Advocacy Specialist (FAS), you would be able to see all FAP cases within the entire Coast Guard. However, you would not be able to see details for Substance Abuse, Special Needs or other program area cases. Listed below are the Functional Roles that appear on CG-7421G, and that can be granted:

oFamily Advocacy Specialist o Family Resource Specialist o Substance Abuse CDAR

Revised: 10/7/2020


oSubstance Abuse SAP

oSexual Assault Specialist

oCritical Incident Stress Management Specialist (CISM)

oEmployee Assistance Specialist

oWorkplace Violence & Threatening Behavior Specialist

oVictim Witness Specialist

An individual could have multiple Functional Roles depending on their position within the organization (e.g. Special Needs and Family Advocacy). In this example, you would have access to both Special Needs and Family Advocacy cases. If this situation arises, the individual can request both roles using one CG-7421G.

Program Managers and HSWL Service Center Work-Life Program POCs will have access to all cases within their respective programs.

oFamily Advocacy PM

oSpecial Needs PM o Substance Abuse PM o Sexual Assault PM

o Critical Incident Stress Management PM o Employee Assistance PM

o Workplace Violence & Threatening Behavior PM o Victim Witness PM

Revised: 10/7/2020


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