**UNITED STATES DEPARTMENT OF AGRICULTURE**

**DOCUMENTARY MATERIALS REMOVAL/NON-REMOVAL CERTIFICATION**

**AND NON-DISCLOSURE AGREEMENT**

[In Accordance with DR 3100-001, Records Management Policy for Departing
Employees, Contractors and political Appointees]{.underline}

**Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Office:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Telephone Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Planned
Departure Date: \_\_\_\_\_\_\_\_\_\_\_\_**

1.  **Documentary Materials that May be Removed: Personal Papers.**

> Examples of personal papers include: papers accumulated by an official
> before joining Government service that are not used subsequently in
> the transaction of Government business; materials relating solely to
> an individual\'s private affairs, such as outside business pursuits,
> professional affiliations, or private political associations that do
> not relate to agency business; diaries, journals, personal
> correspondence, or other personal notes that are not prepared, used
> for, circulated or communicated in the course of transacting
> Government business (36 C.F.R., Section 1222.36(a), (b), and (c)).

2.  **Records that May Not be Removed.**

    a.  Any material regardless of the media that meets the definition
        of a Federal Record.

    b.  Any information not normally released to the general public,
        unless prior approval is obtained.

3.  **Penalties for Unlawful Removal of Records.**

> Criminal penalties are provided for the unlawful removal or
> destruction of Federal records (18 U.S.C. 641 and 2071) and for the
> unlawful disclosure of certain information pertaining to national
> security (18 U.S.C. 793, 794, 798 and 952).

4.  **Refer to Appendices A and B. The checklist (Appendix B) must be
    completed.\
    \
    **

5.  **Are you removing any nonrecord documents, such as extra copies of
    agency records, from the Department of Agriculture? If yes, go to a.
    If no, go to b.**

    a.  Complete the below certification with the Reviewing Official.

> I certify that the documents that I am removing from the Department of
> Agriculture have been reviewed and approved for removal. They do not
> include any documents relating to any pending or contemplated civil,
> criminal, or administrative proceeding or other program information,
> that if released, would impair or prejudice the outcome of the
> proceeding or Government policy determinations, decisions, or other
> actions (Examples: classified documents; record copies; documents,
> even though judged to be nonrecords, that will create a gap in the
> files; and indexes and finding aids necessary to use the official
> files).
>
> I agree to keep all nonpublic materials absolutely confidential and
> will not disclose their contents or existence without prior permission
> from the appropriate Department of Agriculture Official.
>
> Employee's Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> Date: \_\_\_\_\_\_\_\_\_\_\_\_
>
> Program Manager's Name:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Organization and Title of Program
> Manager:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Telephone Number: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Signature of Program Manager: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> Date: \_\_\_\_\_\_\_\_\_\_\_
>
> Agency Records Officer or\
> Field Office Records Liaison Name:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
>
> Signature of Agency Records Officer or Field Office
>
> Records Liaison:
> \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date:
> \_\_\_\_\_\_\_\_\_

b.  Complete the certification below.

> I certify that I am not removing any documents from the Department of
> Agriculture.
>
> Employee's Signature: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
> Date: \_\_\_\_\_\_\_\_\_\_\_\_

Appendix A

**PRIVACY ACT GUIDANCE FOR DEPARTING EMPLOYEES**

The Privacy Act, 5 U.S.C. § 552a, prohibits the disclosure of certain
records about an individual except under certain specified
circumstances. This document provides a practical guide for those
employees who are unfamiliar with the specific requirements of the
Privacy Act. We note that this guide probably prohibits the removal of a
broader range of materials than would be prohibited by the statute.
Therefore, if you follow the guidance, you will not violate the Privacy
Act. You are free, however, to consult the statute itself to determine
how to comply with the Privacy Act.

As an employee of the Department of Agriculture, you are entitled to
have access to records or copies of records about an individual when
such access is necessary for you to perform your official duties.
However, once you cease to be an employee of the Department, you are no
longer entitled to the special access that you previously had by virtue
of that position. This is true even if you authored or had a role in the
preparation of particular records.

Consequently, upon your departure, you should not remove any records or
copies from the Department that are about an individual. Generally, a
record is about an individual if it contains some substantive
information about the individual (e.g., employment records, medical
records, home address). A record is not about an individual if it is
about a person or entity that is not afforded Privacy Act protection
(e.g., a corporation or organization, a person who is neither a U.S.
citizen nor a permanent resident, or a deceased person); if it does not
identify the individual who is the subject of the record by name or
other identifier and provide information about that individual (e.g., an
agency memorandum that contains the name of the author of the
memorandum, the name of the recipient, and perhaps even other employee
names on a distribution list but that does not contain any information
about those or any other individuals mentioned in the record). The
Department may permit you to take materials about an individual if they
officially have been placed in the public domain.

Appendix B

**RECORDS MANAGEMENT EXIT CHECKLIST**

1.  Departing employees shall meet with their Federal supervisor or
    Contracting Officer's Technical Representative (COTR) and the Agency
    Records Officer or Field Office Records Officer to:

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a.  Identify location and content of all record/nonrecord material in
    employee's custody, **regardless of media** (paper, computer hard
    drive, compact disks, email, servers, etc.);

    1.  Identify for reassignment active records needed for work in
        progress;

    2.  Identify for reassignment classified and vital records;

    3.  Identify employee personal papers and nonrecord copies for
        removal;

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b.  Return any records taken from file stations or records repositories;

c.  Turn in file cabinet keys, vault/restricted access combinations, and
    computer/system passwords needed for access.

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2.  Agency Records Officers or Field Office Records Officer shall ensure
    that:

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a.  All record/nonrecord documents and files of departing employees are
    inventoried;

b.  All records are scheduled and sent to a records management custodian
    unless reassigned to another employee by the Federal supervisor or
    COTR;

c.  Prepare an SF-115 "Request for Records Disposition Authority" to
    schedule any unscheduled records;

d.  Permanent records that are no longer needed by the Department are
    sent to the National Archives;

e.  Employee files residing on servers, hard drives, and in email
    systems are:

    1.  reviewed for record material,

    2.  reassigned to another employee, and/or

    3.  dispositioned in accordance with approved schedules;

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f.  Records are not destroyed:

    -   without an approved records disposition schedule,

    -   until they have satisfied retention requirements,

    -   if they come under an epidemiology, litigation or other
        moratorium.

        3.  The Federal employee's supervisor or contractor's COTR shall
            ensure that:

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a.  Active records needed for work-in-process and classified, quality
    assurance, and vital records are reassigned to another employee
    (with appropriate clearance);

b.  Inactive records are transferred to a records management custodian;

c.  Controlled operating manuals and handbooks are collected;

d.  Removal of material by the employee is documented and limited to
    personal papers and a pre-approved amount of nonrecord copies.

Federal supervisors, COTRs, and records staff shall document and report
the unauthorized destruction or loss of records to the Departmental
Records Officer.

The employee shall certify that all Federal documents, records and files
created or received have been transferred to a records management
custodian, a COTR, or custody has been reassigned to another employee.

The Federal employee's records official (Headquarters -- Program Records
Official; Field -- Records Management Field Officer) or the contractor
employee's COTR shall initial the certification.