Form 10042 (12/07) 10042 (12/07) Notice for 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: 1640-0012

4. Expiration Date: 08/31/2010

5. Agency Form Number: DHS Form 10042 (12/07)

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 For Certificate of Data Destruction

Reference Issue #:

Dear ________________:

This document is used by the PREDICT Coordinating Center (PCC) to notify a Researcher/User that a Memorandum of Agreement (MOA) and access to approved datasets has expired. Our records indicate that your MOA, MOA ID ___________, between ___________________________ and the PCC, and authorization to use the PREDICT datasets listed below expired on _____________.

Under the terms of the MOA, upon expiration of the MOA and access to the datasets, you agreed to provide to the PCC with a Certificate of Data Destruction certifying that any and all copies of the datasets, whether in whole or in part or on your system or not, have been deleted from all systems and permanently destroyed.

The attached Certificate of Data Destruction must be completed, signed, and returned to the PCC by __________________. The Certificate may be faxed to Ms. Renee Karlsen at (866) 835-0255 (toll free) or emailed in pdf format to [email protected]. Questions may be directed to Ms. Renee Karlsen by telephone at (919) 541-7115 or via email at [email protected].

DATASET(S) TO WHICH ACCESS HAS EXPIRED:

Please Fill in Contact Information

Name
Title
Organization
Address
City		State		Zip
Email
Phone
Fax

PREDICT

Certificate of Data Destruction

__________________________________________________________________________________

To be completed by the Person Responsible for the Data (Researcher/User if an individual or Data Custodian if MOA is with an entity)

MOA ID _______________

Project Title:

Researcher or Data Custodian Name (Printed or Typed):

Name of Organization:

I hereby certify that ALL of the following listed datasets and any copies thereof, whether paper or digital or whole or partial, which were approved for use in MOA ID ______ , have been deleted from all systems and permanently destroyed. This includes all datasets or copies of the datasets held by persons other than myself who were approved for access under the MOA.

DATASET(S) DELETED OR DESTROYED:

Date of Data Destruction: ______________________________

Date Certificate of Destruction Signed:___________________________

Signature of Researcher/Data Custodian_________________________________

To be completed by PREDICT Coordinating Center:

Date of PCC’s receipt of Certificate of Destruction:_________________________