Form 10042 (12/07) 10042 (12/07) Certificate of Data Destruction

DHS PREDICT Certificate of Data Destruction Form
Cover Sheet
1. Department Name: Department of Homeland Security
2. Component/Agency Name: Science and Technology Directorate
3. OMB Control Number: 1640-New
4. Expiration Date: TBD (Three years from approval date)
5. Agency Form Number:
6. Name of Form: Certificate of Data Destruction
7. Purpose of Form: Certifies that all datasets used were destroyed as required by
PREDICT
8. How to submit: Fax to RTI International, Attn: Renee Karlsen, 866.635.0255
(toll free fax).

PREDICT
NOTICE OF DATASET ACCESS/
APPLICATION EXPIRATION
Reference Issue #: 1223
Dear: FName LName
Our records indicate the following:
Your application to access the datasets listed below remains pending because the
Memorandum of Agreement (MOA) has not been received by the PREDICT Coordinating
Center (PCC).

.

Your authorization to access the datasets listed below will expire on
You must take the necessary measures to:

Request an extension of the deadline to submit an executed MOA. The request must be
received by the PCC within 14 working days of this notice or your application will be
cancelled.
Request a dataset access deadline extension. For authorization to continue access to a
dataset, the request must be received by the PCC at least seven (7) working days before
the expiration of your access.
Certify to the PCC that you have deleted the dataset(s) for which your access has
expired from your system. This must be completed within thirty (30) days of the
expiration of access to the dataset(s). The forms you will need to do this are attached
and instructions for completing and submitting them are provided below.
Dataset(s):
1. ddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddddd
2. ddddddddddddddddddddddddddddddddddddddddddddd
3. ddddddddddddddddddddddddddddd
4. ddddddddddddddddddddddddddddddddddddd
5. dddddddddddddddddddddddddddddddddddddddd
6. dddddddddddddddddddddddddddddddddddddddd
7. ddddddddddddddddddddddddddddddddd
8. dddddddddddddddddddddddddddddddddddd
9. ddddddddddddddddddddddddddddddddddd
10. ddddddddddddddddddddddddddddddddddddddd

Thank you for your participation in the PREDICT community.
An agency may not conduct or sponsor an information collection and a person is not required to respond to
this information collection unless it displays a current valid OMB control number and an expiration date. The
control number for this collection is 1640-XXXX and this form will expire on XX/XX/XXXX. The estimated
average time to complete this form is 15 minutes per respondent. If you have any comments regarding the
burden estimate you can write to Department of Homeland Security, Science and Technology Directorate,
Washington, DC 20528.

DHS Form 10041 (12/07)

Page 1 of 4

Directions:
1. To apply for an extension for accessing datasets or submitting an MOA:
a. Copy the letter outline that begins on Page 3 to your institution’s letterhead
and format for a letter.
b. Fill in appropriate names, dates and other information where indicated,
deleting bracketed instructions. Do not skip any step.
c. Choose one extension request. You may not combine extension requests.
d. Use one letter per project. Multiple projects may not be referenced in a
single letter.
e. Spell out the name of your company, organization, school and/or
department. Do not abbreviate.
f. Use first and last names at all times. Optional: Insert the prefix appropriate
to the researcher(s) (Dr., Ms, Miss, Mrs., Mr.)
g. Print out a copy of the completed letter.
h. Sign the letter and return it to the PCC using the fax number below. An
executed copy will be returned to you for your files.
2. To certify deletion of dataset(s):
a. Fill in the Certificate of Data Destruction on Page 4 and print it out.
b. Fill out form completely, including dataset name(s). Missing information
will void the form. Optional: If the list of datasets it too long for the pace,
you may list them on a separate page and attach it to the completed
certificate. If this option is used, write “See attached page” in the section
that requests the dataset list.
c. Spell out the name of your company, organization, school and/or
department. Do not abbreviate.
d. Use first and last names at all times. Optional: Insert the prefix appropriate
to the researcher(s) (Dr., Ms, Miss, Mrs., Mr.)
e. Sign the form.
f. Return it to the PCC using the fax number below. An executed copy will be
returned to you for your files.
Questions regarding your application may be directed to the PREDICT Coordinating
Center, at [email protected]
FAX

RTI International
Attn: Renee Karlsen
866.835.0255 (toll free fax)

DHS Form 10041 (12/07)

Page 2 of 4

[INSERT DATE]
RTI International
Attn: Renee Karlsen
PREDICT Coordinating Center
PO Box 12194
Research Triangle Park, NC 27709-2194

Dear Ms. Karlsen:
I am writing regarding a pending PREDICT application, reference Issue # 1223

.

By this letter, I am requesting an extension for the action, period, and reason specified below
(Choose only one):

1. Extend period to submit MOA
I wish to request that the time period to submit an executed Memorandum of Agreement with my
application for dataset access be extended. I understand extensions are granted in 30-day
intervals. If the MOA has not been completed within that time period, I understand I will need to
reapply for another extension.
2. Extend access to dataset(s)
I wish to request an extension of access to the following dataset(s) by [LIST FULL NAMES OF
RELEVANT STAFF] until [INSERT DATE.] I understand extensions are granted in three-month
intervals, and I will need to reapply for another extension for access beyond the three-month
period. This extension is necessary because [GIVE SHORT REASON FOR THE NEED FOR AN
EXTENSION.]
Dataset(s) for which extension is requested:
1. ddddddddddddd
2. ddddddddddddd
3. ddddddddddddddd

Thank you for your attention to this matter. Should you need further information, please contact
me via email at [INSERT EMAIL ADDRESS] or by telephone at [INSERT PHONE NUMBER.]
Very truly yours,
Print Name:
Signed:
Title, Position:
To be completed by PREDICT Coordinating Center
Acknowledged:
Print Name:
Signed:
PREDICT Coordinating Center authorized signature
Date:

DHS Form 10041 (12/07)

Page 3 of 4

PREDICT
CERTIFICATE OF DATA DESTRUCTION
To be completed by the Person Responsible for the Data (Researcher)
ddddddddd

Project Title
dddddddddd

Researcher Name (Printed or Typed)
dddddddd, dddddddd

Name of Organization & Department

I hereby certify that ALL copies of the following dataset(s) approved
for use in Issue # 1223
have been permanently
destroyed.
DATASET(S):
1. dddddd
2. ddddddd
3. dddddd
4. ddddddd

Date of data destruction:

______________________________

Researcher Signature

Date

To be completed by PREDICT Coordinating Center:
Date of receipt of Certificate of Destruction

Data Receipt Signature

DHS Form 10042 (12/07)

Date

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