36C10E18Q9417-002.pdf

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Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA DIRECTIVE 6300

Transmittal Sheet

July 10, 2012

RECORDS MANAGEMENT

1. REASON FOR ISSUE. This Veterans Health Administration (VHA) Directive establishes authority and policy for a formalized VHA records management program and defines the roles and responsibilities for all VHA personnel in response to Department of Veterans Affairs (VA) policy and mandates of the National Archives and Records Administration (NARA). Authority:

Title 36, Code of Federal Regulations (CFR), Chapter XII, Subchapter B.

2. SUMMARY OF CONTENT. This Directive defines the policy for carrying out the records management program, assignments of duties, and the establishment of records managers and records liaisons within all VHA facilities. NOTE: These policies were developed based on, and in conjunction with, records management requirements contained in various Federal regulations, guides, bulletins, and memoranda published by NARA.

3. RELATED ISSUES. VA Directive 6300.

4. RESPONSIBLE OFFICE. The VHA Office of Informatics and Analytics, Health Information Governance (10P2C) is responsible for the contents of this VHA Directive.

Questions may be addressed to (202) 341-9881.

5. RESCISSIONS. VHA Directive 6300, dated September 22, 2011, is rescinded.

6. RECERTIFICATION. This VHA Directive is scheduled for recertification on or before the last working day of July 2017.

Robert A. Petzel, M.D.

Under Secretary for Health

DISTRIBUTION: Emailed to the VHA Publications Distribution List 07/11/2012

July 10, 2012 VHA DIRECTIVE 6300

RECORDS MANAGEMENT

1. PURPOSE: This Veterans Health Administration (VHA) Directive defines policies for the establishment and maintenance of a formalized records management program within all VHA organizational components, e.g., program offices, Veterans Integrated Service Networks (VISN), and medical facilities. It establishes the roles and responsibilities for VHA personnel to create, manage, use, store, and dispose of VHA Federal records in accordance with Department of Veterans Affairs (VA) policy and the National Archives and Records Administration (NARA).

Authority: Title 36 Code of Federal Regulations (CFR), Chapter XII, Subchapter B.

2. BACKGROUND

a. The Federal Records Act of 1950, as amended, contains the statutory authority for the VHA Records Management Program. Government-wide responsibility for Federal recordkeeping is shared by the General Services Administration (GSA) and NARA.

b. Title 44 United States Code (U.S.C.) §§ 3301 through 3314 establishes the legal basis for the disposal of records of the United States Government.

c. The Paperwork Reduction Act, 44 U.S.C. Ch. 35, establishes the legal basis for minimizing the cost of the creation, collection, maintenance, use, dissemination, and disposition of information.

d. VA Directive 6300 requires all administration leadership and other key officials to define records programs within VA policy requirements, including the assignment of records managers and the establishment of policies to manage records within the administration.

3. POLICY: It is VHA policy that all Federal records contained on paper, electronic, or other medium are properly managed from their creation through their final disposition, in accordance with Federal laws, the General Records Schedule (GRS) and VHA Records Control Schedule (RCS) 10-1. NOTE: The GRS can be found at www.archives.gov.

4. RESPONSIBILITIES

a. The Under Secretary for Health. The Under Secretary for Health, or designee, is responsible for:

(1) Ensuring an effective VHA records management program is maintained.

(2) Ensuring a vital records program is maintained to guarantee the continuity of essential Federal Government activities during and following a national emergency, a technological or natural disaster, and to protect the rights and interests of VA beneficiaries and employees.

(3) Ensuring all VHA records are appraised and their approved retention periods published in RCS 10-1.

http://www.archives.gov/

VHA DIRECTIVE 6300 July 10, 2012

(4) Ensuring records not identified or described in RCS 10-1 and not published in the GRS are unscheduled records. Unscheduled records are not destroyed until a disposition authority is approved by NARA. All unscheduled records are dispositioned in accordance with their approved authority. After the authority is established and approved by NARA, it is published in

RCS 10-1.

(5) Ensuring the records management program enables records to be accessed when requested, regardless of medium.

NOTE: All VHA records are subject to the provisions of the Privacy Act (PA), the Freedom of Information Act (FOIA), the Health Insurance Portability and Accountability Act (HIPAA), and VA’s confidentiality statute.

b. Director, Health Information Management. The Director, Health Information Management, or designee, is responsible for:

(1) Designating the VHA Records Officer, and

(2) Overseeing VHA records management operations.

c. VHA Records Officer. The VHA Records Officer, or designee, is responsible for:

(1) Developing and maintaining VHA-specific policies and procedures for the development, maintenance, storage, and disposition of Federal records created within VHA.

(2) Developing and maintaining VHA RCS 10-1, in accordance with NARA requirements.

(3) Managing applications and petitions for modification of existing records schedules and future RCS requests.

(4) Developing and maintaining a formal records management program specific to records created, used, stored, and dispositioned within VHA Central Office.

(5) Distributing policies, procedures, and notifications from the VA Records Officer or NARA to all VHA records managers and other appropriate personnel.

(6) Providing guidance on VHA applicability of VA policy and NARA requirements to VHA staff.

(7) Monitoring the training of all VHA records managers and records liaisons as described in this Directive (see subpar. 4f(8) and subpar. 4h(3)).

d. VHA Privacy Compliance Assurance Officer. The VHA Privacy Compliance Assurance Officer is responsible for ensuring that monitoring for compliance is conducted and in accordance with NARA Regulation, Subpart B, § 1220.34.

e. VHA Program Chief Officer, VISN Director, and Facility Director. Each VHA Program Chief Officer, VISN Director, and Facility Director, or designee, is responsible for:

(1) Assigning an official records manager and alternate records manager for their program office or facility. NOTE: This may include assignment of more than one records manager for health systems with large campuses or for program offices in multiple physical locations.

(2) Assigning official records liaisons for each section within their operations. Each assigned liaison is responsible for records management compliance within that section.

(3) Ensuring the program office, VISN, or facility meets all requirements for the creation, maintenance, use, storage, and disposition of Federal records generated or obtained within their operations, i.e., the life cycle of records.

(4) Ensuring storage locations for Federal records meet the requirements of 36 CFR 1228, Subpart K, which contains NARA-specific requirements for Federal record storage facilities.

(5) Ensuring all employees complete the VA Talent Management System (TMS) course, “Privacy and Information Security Awareness and Rules of Behavior” in order to fulfill the annual NARA training requirement of 36 CFR 1222.24(b). NOTE: VHA Training is available at: https://www.tms.va.gov.

f. Facility Records Manager, or Alternate. The Facility Records Manager, or alternate, is responsible for:

(1) Development and dissemination of local facility-specific policies and procedures related to records management within their facility operations.

(2) Maintenance of a facility-wide records inventory.

(3) Coordination of records storage and disposition with the VA Records Center and Vault or other NARA-approved records storage facilities.

(4) Maintaining current knowledge of records management requirements, including VA and VHA policies related to records management, and changes in NARA regulations and guidance.

(5) Ensuring all records liaisons are trained on the creation, maintenance, use, storage, and disposition of the records created within their area of responsibility, i.e., the life cycle of records.

(6) Maintaining and destroying Federal records in the facility within the specified time frames defined in VHA RCS 10-1 or GRS, and in accordance with VA and VHA destruction policies.

(7) Ensuring the facility records management program is applied to all business information within the facility, including electronic record, audiovisual record, paper record, or any other media formats.

https://www.tms.va.gov/

(8) Completing the VA TMS course, “Role-Based Records Management Training for VA Personnel”. After completion of this course, annual refresher training will be required. As the Records Manager or Records Liaison function is not always apparent by occupational title or other Personnel and Accounting Integrated Data (PAID) field, facilities will need to assign the role-based training locally. NOTE: VHA Training is available at: https://www.tms.va.gov.

(9) Maintaining the facility’s vital records in accordance with VHA RCS 10-1 and local records management policies and procedures.

(10) Evaluating the facility’s records management program on a regular basis and ensuring unscheduled records are brought to the attention of the VHA Records Officer, who assists in conducting a records appraisal, as appropriate.

(11) Resolving records management issues that arise at the facility.

(12) Apprising facility leadership on matters relating to records management activities.

(13) Reviewing facility contracts that create, use, store, and destroy Federal records in order to ensure compliance with all records management regulations.

g. Service Chiefs, Product or Service Line Managers, and Program Supervisors or Managers. The Service Chiefs, Product or Service Line Managers, and Program Supervisors or Managers are responsible for:

(1) Appointing a records liaison to support the records manager.

(2) Ensuring the records liaison and records manager are fully involved in all projects concerning the creation, maintenance, use, and disposition of all facility records.

(3) Ensuring all service and program employees are aware of, and abide by, policies outlined in this Directive.

(4) Seeking advice and assistance, as needed, from the VHA Records Officer concerning records management problems or concerns.

(5) Ensuring departing employees do not remove Federal records from VHA custody.

h. Records Liaisons. The Records Liaisons are responsible for:

(1) Creating a records inventory for records within their department.

(2) Modifying any business processes within their department that impact the ability to meet NARA, VA, or VHA policy requirements related to records management.

(3) Completing the VA TMS course, “Role-Based Records Management Training for VA Personnel”. After completion of this course, annual refresher training will be required.

As the Records Manager or Records Liaison function is not always apparent by occupational title or other PAID field, facilities will need to assign the Role-based training locally. NOTE: VHA Training is available at: https://www.tms.va.gov.

(4) Ensuring that all records in their Department are stored in accordance with NARA requirements for a Federal storage facility.

(5) Ensuring that all records in their Department are maintained and destroyed in accordance with VHA RCS 10-1 and the GRS.

(6) Implementing the facility’s Vital Records Program (see subpar. 6n).

i. All VHA Personnel. All VHA personnel are responsible for:

(1) Completing the VA TMS course, “Privacy and Information Security Awareness and Rules of Behavior” in order to fulfill the annual NARA training requirement of 36 CFR 1222.24(b). NOTE: VHA Training is available at: https://www.tms.va.gov.

(2) Understanding what constitutes a Federal record and applying VA, VHA, and NARA regulations and guidance to all Federal records with which they come in contact.

(3) Ensuring Federal records in their custody are maintained and disposed of in accordance with VHA RCS 10-1 or the GRS.

5. REFERENCES

a. Title 44 U.S.C. Chapter 31.

b. Title 44 U.S.C Chapter 33.

c. Title 44 U.S.C. Chapter 35.

d. Title 36 CFR Chapter XII, Subchapter B.

e. Office of Management and Budget (OMB) Circular A-123.

f. OMB Circular A-130.

g. General Records Schedule.

h. VA Directive 6300.

i. VA Handbook 6300.1.

j. VA Handbook 6300.2.

k. VA Handbook 6300.3.

l. VA Handbook 6300.4.

m. VA Handbook 6300.5.

n. VA Handbook 6300.6.

o. VA Handbook 6300.7.

p. VA Handbook 6300.8.

q. VA Handbook 0320.

r. VHA RCS 10-1.

s. VHA Handbook 1907.01.

6. DEFINITIONS

a. Audiovisual Records. Audiovisual records are records in pictorial or audio form, which include motion pictures, still pictures, sound recordings, video recordings, graphic materials such as posters and original art, audio and video recordings, and combinations of media such as slide tape productions.

b. Disposal. Disposal means the removal of records from VA control and authority by their sale, donation, or assignment of legal custody or title to others (Federal or non-Federal entities), or by their physical destruction, sale as waste material, or other forms of salvage or transfer (includes erasure of information captured or maintained on electronic media).

c. Disposal Authority. Disposal authority is the legal authorization obtained only from the Archivist of the United States, NARA, for the disposal of records and recorded information.

d. Disposition. Disposition means an interim or final placement of records or recorded information and the actions taken to maintain them in a proper place following their appraisal.

This includes the actions of (1) retaining; (2) transferring to a records center for temporary storage; (3) transferring to an archival agency; (4) donation to an eligible repository; and (5) image reproduction or destruction.

e. Electronic Records. Electronic records is a category of machine-readable records in which the information is represented by electronic impulses on a magnetic medium, such as magnetic tape, disk, or diskette, and which requires the use of specialized equipment to convert the information to human-readable form.

f. Life Cycle of Records. Life Cycle of Records refers to the management concept that records pass through three stages: creation, maintenance, use, and disposition.

g. Records. "Records" means all books, papers, maps, photographs, machine-readable materials, or other documentary materials, regardless of physical form or characteristics, made or received by an agency of the United States Government under Federal law or in connection with the transaction of public business and preserved or appropriate for preservation by that agency or its legitimate successor as evidence of the organization, functions, policies, decisions, procedures, operations, or other activities of the Government or because of the informational value of data in them (see 44 U.S.C. Ch. 33, Sec. 3301).

h. Records Appraisal. Records appraisal is the process of determining the value and, thus, the final disposition of records and information based upon their administrative, financial, and other uses, their evidential, legal, and informational or research value, their arrangement and relationship to other records, and their historic value to VA, other agencies of the Federal Government, or to the general public.

i. Records Liaison. A Records Liaison is the program, service, or service line representative who works in conjunction with the Records Manager to ensure proper management of all records that are created and maintained by the program, service, or service line.

j. Records Management. Records management is the managerial activities associated with records creation, maintenance, use, and disposition of records in order to achieve adequate and proper documentation of the policies and transactions of the Federal Government and effective and economical management of VA operations.

k. Records Manager. The Records Manager is the person who has designated responsibility for managing and coordinating a records management program for a respective organization.

l. Temporary Records. Temporary records are records approved by NARA for disposal, either on an immediate basis or after a specified retention period.

m. Unscheduled Records. Unscheduled records are records whose final disposition has not been approved by NARA.

n. Vital Records. Vital records are records essential for maintaining the continuity of activities during and following a national or regional emergency.