Appointment date: __________________, /200__  at (time:) ________

1. Name of Department, Division, or Unit: ___________________________________

2. Name of Office: _______________________________

3. Address: ____________

4. Administrator:_________________________________

5. Phone: 247-7________

6. Function of Office: ____________________________________________________

_______________________________________________________________________

7. Offices under this One: ________________________________________________

_______________________________________________________________________

8. Types of Records: _____________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

9. Total Volume of Records in this Office: ______________________________________
 

10. Retention Periods for Records Kept in this Office: _________________________________
 

11. Retention Periods for Records Kept in this Office's Own Storage Areas:____________________
 

12. Departmental Storage Location: ____________________________________________
 

13. Basis for Retention Periods (10. and 11.): ______________________________________
 

14. Present Office Procedures for Disposal: trash.....shred.....records center.....archives....other
 

15. Data Stored on Computer: ________________________________________________
 

16. Automated System: mainframe office pc departmental system
 

17. Disposition of Hard Copy of Computer-stored Data:

destroyed: basis______________________________________________________________________

retained: basis________________________________________________________________________
 

18. Retention Period of Computer-stored Data: ____________________________________
 

19. Are Any Records Microfilmed? yes no Describe: ________________________________
 

20. Originals of Microfilmed Records:

destroyed: basis______________________________________

retained: basis_________________________________________________________________________
 

21. Retention Period for Microfilm: ____________________________________________
 

22. Special Difficulties with Retrieval: __________________________________________
 

23. Vital Records: ___________________________________________________________
 

24. Back-up System: _________________________________________________________
 

25. How Are Records Safeguarded? _____________________________________________
 

26. Access: (circle one): unlimited...... limited ......(to whom?______________________________)
 

27. Procedures for Maintaining Confidentiality: ______________________________________
 

28. Copies Sent to Other Departments: ____________________________________________
 

29. Other Depts' Copies Maintained in this Dept.: ____________________________________
 

30. In-house Publications: (title, frequency, and circulation)
 

31. Comments or Recommendations by Administrator:
 
 
 

32. Additional Comments: (use other side if necessary)
 
 
 
 

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Page last modified: November 30, 2001