Video Surveillance
Request Form
Pursuant to Linn Benton Community College policy, all video surveillance on the property of any LBCC campus must be approved via a
Video Surveillance Request prior to installation, modification, or change to any camera system. Completion of this form is only an
application and does not constitute approval for any installation, modification, or change for any video surveillance. You will be notified in
writing by the Safety & Loss Prevention Manager at such time that any installation, modification or change is either approved or denied. The
Public Safety Office does not accept any responsibility for video surveillance which is installed, modified, changed, or used in any manner
outside the approval or in violation of college policy.
Requesting Department _
Division
Person making the request
Phone:
Video camera(s) to be used for the following purpose:
□Crime deterrence (Theft, vandalism, trespassing, etc.)
□Monitor restricted areas for unauthorized persons (cash registers, equipment storage, shops, compound, labs,
etc.)
□Safety of students or staff: (specify concern)
__________________________________________________________________________________
__________________________________________________________________________________
□Other, Please explain:
Do you need to record video images, have video monitored live, or both? _______________
Duration of camera use:
□Indefinite
□Temporary
From:________To:
Person/s having access to recorded images: __________________________________________________
Number of video cameras to be installed/modified/changed:
*Please attach a detailed description of the exact location(s) of the requested surveillance camera to be installed,
modified or changed—also describe the direction the camera(s) will be pointing (the viewing area).
Signature of Divison/Department Dean or Director
Printed Name
Date
The Public Safety Office will be given access to all stored and live recorded images from any new or
existing cameras installed on LBCC property.
Return completed form to the Safety & Loss Prevention Dept., RH121B. Once approved by the
Surveillance Committee, this form will be retained in the Safety & Loss Prevention office for a period of
five years.
FOR OFFICE USE ONLY
Proposed camera types and locations are in compliance with LBCC Video Surveillance Policy. In addition, they
have been reviewed and are approved by the Surveillance Review Panel.
□Agree
□Disagree
Surveillance Review Panel Chair
Date
IT Director
Date
Comments:
□Agree
□ Disagree
Comments:
FINAL APPROVAL
VP, Finance & Operations
Date