Box ______of ______ / Temporary Box #: / Permanent Box #:
Instructions: / Scan and save the completed form as PDF after Destructions Completed by section has been filled in.
Retain a copy for your Department or Faculty records.
Confirmations: / The Records listed below are scheduled to be destroyed as indicated in the Records Retention Schedule (RRS).
The Records are not the subject of any current or outstanding claim, litigation, investigation, legal hold or audit.
This destruction record documents compliance with FIPPA, Disposal of Personal Information, Regulation 459, S.6(1) and (2).
CONTACT
Department/Unit: / Contact Person: / Telephone/E-mail: / Date:
APPROVALS
Approved by: (name) / Position Title: / Signature: / Date:
RECORDS LISTING/DESCRIPTIONS /
File No. / Records Class / Retention Period / Records Class / File Title /
Brief Description / Date Range (Years) / Media / # Of Files / Destruction Method /
From / To /
Press Tab to add additional lines
DESTRUCTIONS COMPLETED BY
Name: / Position Title: / Method: / Date:
Prior to beginning any destruction related process, please contact the Records Management Coordinator at .
To use this form, complete the sections as follows:
1. Contact – this should list the person coordinating the work of listing the files to be destroyed.
2. Approvals – all destructions must be authorized by a senior person in the department, this should be a Director or higher.
3. Records Class and Retention Period – will be provided by the Records Management Coordinator during discussions about destroying records.
4. Records Listing/Descriptions – add information to the Records Class / File Title / Brief Description column, the date range of the files – entering just a start year and end year is sufficient, if no dates are found add unknown.
5. Media – usually this will be paper, but it may also be other media such as electronic files, audio tapes, video tapes, CDs.
6. # Of Files – count the approximate number of files in the group or provide a range of files (optional).
7. Destruction method – indicate the destruction method used – Confidential Shredding bin, Boxes picked up by Shredding company, etc… Note: Records containing confidential, sensitive or privileged information such as Student records must be securely destroyed.
8. Destructions Completed by – the name and details of the person who performed the destructions and date the destruction was completed. If the destructions are completed by a third party, attach any documentation regarding this destruction or indicate date the records were picked up.
9. Retain a copy of this form for your records.
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