Records Disposition Form - MIS 07

By Frances Jordan,2014-12-29 14:17
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Records Disposition Form - MIS 07



    (This form can be completed in Word, Printed out and Signed, and then sent to MIS Dept.)

Item #1, 2 - Are self explanatory.

    Item #3 - Mark method of disposal. Landfill disposal cannot be used for records containing

    confidential information including social security and student identification numbers.

    Contact MIS if necessary.

Item #4 Your Principal or Coordinator / Dept. Head must sign this line.

Item #5a Schedule Number is either GS1-SL or GS7.

    Item #5b Write the ITEM NUMBER given in the Records Management Book GS1-SL or GS7 for

    the item being destroyed. (Example: Item 53)

    Item #5c Write the TITLE as given in the Records Management Book. (Do Not use the name that

     you call the document.)

Item #5d Enter retention time according to the Records Management Book.

     (Example: 3 yrs., 5yrs, OSA, etc..)

Item #5e Enter the dates of the documents being destroyed. (Example: 08/04 05/05)

Item #5f Enter the Volume in Cubic Feet according to the chart below.

Item #5g Skip. Used only AFTER approval, if you are shredding documents.

    Item #6 Indicate the location of your boxes so Facilities knows where to pick them up.

Item #7 For MIS Department ONLY.

    Item #8 Only to be filled out by person shredding documents and a witness or Landfill personnel.

    When complete please return to MIS Dept. for approval. If you have any questions, feel free to contact me at extension #5684.

Thank you,

    Teresa Ware

    District Records Custodian

    MIS Department


     L x W x H (in inches)

    ------------------------------- = cubic feet

     1728 inches

     * Standard Case of Copy Paper Box with lid = 1 cubic foot

     * Stor-All 3325Q Quick Fold White Box with lid = 1 cubic foot

    MIS 07.02 Rev. 03/10

    The School Board of Highlands County No. _____


    1. Department/School Name:

    2. Contact Name and Phone Number:

    3. Notice of Intention: The scheduled records listed in item 5 are to be disposed of in the manner checked below.

     a. Destruction (DO Shred) b. Scan then Destruction c. Scan then School Shred d. Shred (Location) e. Destruction (Landfill) 4. Submitted by: I hereby certify that the records to be disposed of are correctly represented below, that any audit

     requirements for the records have been fully justified, and that further retention is not required for any litigation pending

     or imminent.


     Signature Name and Title Date 5. LIST OF RECORD SERIES

     g. f. a. b. e. Disposition c. d. Volume Schedule Item Inclusive Action and Date. Title Retention In Cubic No. No. Dates Completed After Feet Authorization

6. Location of Boxes: Building # Room #

     7. Disposal Authorization: Disposal for the above listed 8. Disposal Certificate: The above listed records have records are authorized. Any deletions or modifications been disposed of in the manner and on the date shown are indicated. in column g. ___________________________________________ Signature Date

     ___________________________________________ Name and Title _____________________________________________ Custodian/Records Management Liaison Office Date

     ___________________________________________ Witness

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