U.S.
EPA Records Destruction Form Sample
(This is a sample form. Use only those fields necessary for your business practices.) Person Completing Form / Organization / Phone No. Records Schedule / Disposition Item
Records Title / Description / ID Format Volume Location Date Range Start End
Close Date Date Eligible for Destruction Destruction Method
Name Custodian Authorizing Official Destroyed by Witnessed by* Comments
Signature
Date
Certification Statement I certify that, to the best of my knowledge, these records are not subject to any current or pending audit, litigation, subpoena, or other legal demand for their retention or disclosure, and they are being destroyed in accordance with the applicable, approved records schedule. I certify that these records were destroyed in compliance with EPAs requirements. I understand that sensitive or confidential records must be destroyed by shredding, burning or other definitive means. All records identified on this form were destroyed on the same date.
*Pertains only to sensitive records.
National Records Management Program
Revised July 17, 2009
Instructions Person Completing Form / Organization / Phone No. Enter your name, organization, and telephone number. The phone number should include the area code and, if applicable, an extension. Records Schedule / Disposition Item Enter the schedule number and the disposition item assigned to the records. For example: 006a where 006 is the schedule # and a is the item. You may only use approved records schedules to authorize records destruction. These schedules can be found at http://www.epa.gov/records/policy/schedule/. Each form should contain records managed under one disposition item. If you are destroying records under another disposition item, use a separate form. Record Title / Description / ID Enter the records title. Optionally, you may also enter a brief description of the records and/or an internal identifier. For example: West Va. Air Quality (FY 01) / State action reports, air quality data, and correspondence / Box #18069 Format Enter the format of the records (e.g., paper, electronic, photographic, microform, video and sound recordings). Volume Enter the volume of record material being destroyed. For paper records, report volume using one of the following: linear feet (e.g., 24) number of files (e.g., 25 files) For electronic records, report volume using one of the following: total size of the files by the easiest and most logical unit (e.g., 2 GB, 100 MB, 100 KB), number and type of media containing the data (e.g., 10 3.5 diskettes, 3 CD-RWs, 1 40 GB hard drive), or Location Enter the storage location of the records. Date Range Start - Enter the earliest date of the records. End - Enter the most recent date of the records. Close Date Enter the date the records became inactive. Eligible for Destruction Date Enter the date the records are eligible for destruction. Calculate the destruction date of the records by adding the retention time specified in the records schedule to the date the records were closed (close date + retention period). Destruction Method Enter the method of destruction used for the records (e.g., recycling, shredding, pulping, physical destruction such as hammering or smashing, demagnetization). Custodian Name - Enter the name of the records custodian. Date - Enter the date signed. Authorizing Official Refer to your offices records management procedures for guidance regarding the authorized official for the destruction of records in your area. Name - Enter the name of the authorizing official. Date - Enter the date signed. Destroyed by Name - Enter the name of the person performing the destruction of the records. Date - Enter the date of destruction. Witnessed by (required for destruction of sensitive records only) Name - Enter the name of the person acting as a witness to the destruction of records by an outside contractor. Date - Enter the date of destruction. Comments Enter additional information about the records (e.g., special circumstances, exceptions).
