STATE RECORDS CENTER STORAGE LIST Form RC-100 (Revised 04/2011) Connecticut State Library Office of the Public Records Administrator State Records Center ACCESSION NO.: 198 West Street Rocky Hill, CT 06067 P: (860) 721-2041 F: (860) 721-2055 E: DATE RECORDS TRANSFERRED: INSTRUCTIONS: See . All records listed on this page must adhere to the same records series and have the same destruction year. List each box individually (one box per row), providing a brief description, range of contents, inclusive dates of records, and box number. Complete this form electronically and submit it via e-mail to . Staff will contact you to schedule a shipment date. If you are a “covered entity” under HIPAA, you should implement technical security measures to guard against unauthorized access to ePHI. AGENCY (include division and address): RMLO OR AUTHORIZED AGENCY PERSONNEL: RMLO PHONE: PAGE OF RECORDS SCHEDULE & SERIES NO. (e.g., S1-015): RECORDS SERIES TITLE (as shown on authorizing records schedule, e.g., Accreditation Records): DESTRUCTION YEAR: DESCRIPTION OF RECORDS (as needed) RANGE OF RECORDS (alphabetical or numerical) DATES OF RECORDS BOX NUMBER RECORDS CENTER LOCATION NO. FROM THRU 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. DESTRUCTION AUTHORIZATION These records have fulfilled the minimum retention period and are now eligible for destruction. Your written approval for such action is required. If there are any records you do not want to destroy at this time, circle the box number and indicate “Do Not Destroy.” You may also request the return of individual files. Any such identified records will not be destroyed and will be returned to agency control. By signing this form, you attest that no records listed, in your opinion, pertain to any pending case, claim, or action. Authorized Agency Representative: (Signature) (Date) DESTRUCTION REVIEWED AND APPROVED BY: State Archivist: (Signature) (Date) Public Records Administrator: (Signature) (Date)
STATE RECORDS CENTER STORAGE LIST Form RC-100 (Revised 04/2011) Connecticut State Library Office of the Public Records Administrator State Records Center ACCESSION NO.: 198 West Street Rocky Hill, CT 06067 P: (860) 721-2041 F: (860) 721-2055 E: DATE RECORDS TRANSFERRED: INSTRUCTIONS: See . All records listed on this page must adhere to the same records series and have the same destruction year. List each box individually (one box per row), providing a brief description, range of contents, inclusive dates of records, and box number. Complete this form electronically and submit it via e-mail to . Staff will contact you to schedule a shipment date. If you are a “covered entity” under HIPAA, you should implement technical security measures to guard against unauthorized access to ePHI. AGENCY (include division and address): RMLO OR AUTHORIZED AGENCY PERSONNEL: RMLO PHONE: PAGE OF RECORDS SCHEDULE & SERIES NO. (e.g., S1-015): RECORDS SERIES TITLE (as shown on authorizing records schedule, e.g., Accreditation Records): DESTRUCTION YEAR: DESCRIPTION OF RECORDS (as needed) RANGE OF RECORDS (alphabetical or numerical) DATES OF RECORDS BOX NUMBER RECORDS CENTER LOCATION NO. FROM THRU 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. DESTRUCTION AUTHORIZATION These records have fulfilled the minimum retention period and are now eligible for destruction. Your written approval for such action is required. If there are any records you do not want to destroy at this time, circle the box number and indicate “Do Not Destroy.” You may also request the return of individual files. Any such identified records will not be destroyed and will be returned to agency control. By signing this form, you attest that no records listed, in your opinion, pertain to any pending case, claim, or action. Authorized Agency Representative: (Signature) (Date) DESTRUCTION REVIEWED AND APPROVED BY: State Archivist: (Signature) (Date) Public Records Administrator: (Signature) (Date)