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+---------+------+-----+------+-------+-------+-----+--------+-------+
| **In    |      |     |      | -     |       | Or  |        |       |
| ventory |      |     |      |   See |       | igi |        |       |
| of      |      |     |      |       |       | nat |        |       |
| Vital   |      |     |      |    in |       | ing |        |       |
| Re      |      |     |      | struc |       | Off |        |       |
| cords** |      |     |      | tions |       | ice |        |       |
|         |      |     |      |       |       | *(  |        |       |
|         |      |     |      |    on |       | IC, |        |       |
|         |      |     |      |       |       | Div |        |       |
|         |      |     |      |   rev |       | isi |        |       |
|         |      |     |      | erse. |       | on, |        |       |
|         |      |     |      |       |       | B   |        |       |
|         |      |     |      | -     |       | ran |        |       |
|         |      |     |      |  Send |       | ch, |        |       |
|         |      |     |      |       |       | etc |        |       |
|         |      |     |      |  comp |       | .)* |        |       |
|         |      |     |      | leted |       |     |        |       |
|         |      |     |      |       |       | NIH |        |       |
|         |      |     |      |  form |       | --  |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      |    to |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      |   the |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      |   NIH |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      |    Re |       |     |        |       |
|         |      |     |      | cords |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      |   Off |       |     |        |       |
|         |      |     |      | icer. |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      | -     |       |     |        |       |
|         |      |     |      |   Use |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      | presc |       |     |        |       |
|         |      |     |      | ribed |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      |    by |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      |   NIH |       |     |        |       |
|         |      |     |      |     M |       |     |        |       |
|         |      |     |      | anual |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      | 1744, |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      |   NIH |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      | Vital |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      |    Re |       |     |        |       |
|         |      |     |      | cords |       |     |        |       |
|         |      |     |      |       |       |     |        |       |
|         |      |     |      |   Pro |       |     |        |       |
|         |      |     |      | gram. |       |     |        |       |
+---------+------+-----+------+-------+-------+-----+--------+-------+
| P       |      | D   | Appr |       | Date  | Cer |        | Date  |
| repared |      | ate | oved |       | App   | tif |        | Cert  |
| By      |      | Pr  | by   |       | roved | ied |        | ified |
| (cu     |      | epa | Offi |       |       | by  |        |       |
| stodian |      | red | cial |       |       | IC  |        |       |
| of      |      |     | with |       |       | R   |        |       |
| r       |      |     | Dec  |       |       | eco |        |       |
| ecords) |      |     | isio |       |       | rds |        |       |
|         |      |     | n-Ma |       |       | M   |        |       |
|         |      |     | king |       |       | ana |        |       |
|         |      |     | A    |       |       | gem |        |       |
|         |      |     | utho |       |       | ent |        |       |
|         |      |     | rity |       |       | O   |        |       |
|         |      |     | *    |       |       | ffi |        |       |
|         |      |     | (sig |       |       | cer |        |       |
|         |      |     | natu |       |       | *   |        |       |
|         |      |     | re)* |       |       | (si |        |       |
|         |      |     |      |       |       | gna |        |       |
|         |      |     |      |       |       | tur |        |       |
|         |      |     |      |       |       | e)* |        |       |
+---------+------+-----+------+-------+-------+-----+--------+-------+
| Item    | T    |     |      |       | M     | Of  | Name   |       |
| No.     | itle |     |      |       | edium | f-S | of     |       |
|         | and  |     |      |       | (     | ite | Per    |       |
| \(1\)   | Des  |     |      |       | Paper | Lo  | son(s) |       |
|         | crip |     |      |       | or    | cat | S      |       |
|         | tion |     |      |       | E     | ion | ending |       |
|         | of   |     |      |       | lectr |     | R      |       |
|         | Rec  |     |      |       | onic) | \(  | ecords |       |
|         | ords |     |      |       |       | 4\) | to     |       |
|         |      |     |      |       | \(3\) |     | Site   |       |
|         | \    |     |      |       |       |     |        |       |
|         | (2\) |     |      |       |       |     | \(5\)  |       |
+---------+------+-----+------+-------+-------+-----+--------+-------+
|         |      |     |      |       |       |     |        |       |
+---------+------+-----+------+-------+-------+-----+--------+-------+

NIH 2805 (Rev. 11/04) FRONT

**Instructions for Preparing**

**Inventory of Vital Records (NIH 2805)**

> Send completed form to the NIH Records Officer, 6011 Executive Blvd.,
> Suite 601.
>
> **ORIGINATING OFFICE**. Show organization responsible for creating
> emergency operating records, e.g., NIH-ORS-DRS.
>
> **PREPARED BY**. Enter name of responsible program official (custodian
> of records) and the date prepared.
>
> **APPROVED BY**. Each inventory shall be reviewed, signed and dated by
> the official with the decision-making authority/responsibility on how
> these records are maintained.
>
> **CERTIFIED BY**. Each inventory shall be reviewed, signed and dated
> by the IC Records Management Officer.
>
> **COLUMN 1**. Number each new item consecutively.
>
> **COLUMN 2**. Self-explanatory.
>
> **COLUMN 3**. Indicate whether the record is paper or electronic.
>
> **COLUMN 4**. Indicate location of alternate storage site of records
> (e.g., other NIH building, contractor facility etc.).
>
> **COLUMN 5**. Self-explanatory.