# AI intended-use statement

Define the proposed use precisely enough to select risks, controls and evidence.

Adapt this worksheet to your applicable procedures, intended use and requirements. Fictional examples are teaching material, not execution evidence.

## Field instructions

- **System and configuration:** Identify the application, version and relevant model/service identifiers.

- **Users and process:** Name the qualified users and the activity supported.

- **Inputs and source documents:** Identify source types, permissions, versions and supported formats/languages.

- **Outputs and reliance:** State the output and how it can influence a decision or record.

- **Permitted use:** Describe the bounded task and approved conditions of use.

- **Exclusions:** State prohibited actions and unsupported uses.

- **Human review:** Specify source verification, independent work, escalation and decision ownership.

- **Acceptance basis:** Link intended use and failure consequences to the planned evidence.

- **Owner and reassessment triggers:** Identify accountable roles and changes that require review.

## Blank worksheet

System / record ID: ____________________

Prepared by / date: ____________________

Required review / approval under local procedure: ____________________

| Field | Your entry |
| --- | --- |
| System and configuration | ____________________ |
| Users and process | ____________________ |
| Inputs and source documents | ____________________ |
| Outputs and reliance | ____________________ |
| Permitted use | ____________________ |
| Exclusions | ____________________ |
| Human review | ____________________ |
| Acceptance basis | ____________________ |
| Owner and reassessment triggers | ____________________ |

### Blank results or assessment rows

| Field | Completed example |
| --- | --- |
| ____________________ | ____________________ |
| ____________________ | ____________________ |
| ____________________ | ____________________ |