36C25520Q0038-006.pdf

VA Privacy Training for Personnel without Access to VA Computer Systems or Direct Access or Use to VA Sensitive Information

The Department of Veterans Affairs, VA must comply with all applicable privacy and confidentiality statutes and regulations. One of the requirements in VA is to have all personnel trained annually on privacy requirements. “Privacy” represents what must be protected by VA in the collection, use, and disclosure of personal information whether the medium is electronic, paper or verbal.

This document satisfies the “basic” privacy training requirement for a contractor, volunteer, or other personnel only if the individual does not use or have access to any VA computer system such as Time and Attendance, PAID, CPRS, VistA Web, VA sensitive information or protected health information (PHI), whether paper or electronic. You will find this training outlines your roles and responsibility for protecting VA sensitive information (medical, financial, or educational) that you may incidentally or accidentally see or overhear.

If you have direct access to protected health information or access to a VA computer system where there is protected health information such as CPRS, VistA Web, you must take “Privacy and HIPAA Focused Training” (TMS 10203). “VA Privacy and Information Security Awareness and Rules of Behavior” (TMS 10176) is always required in order to use or gain access to a VA computer systems or VA sensitive information, whether or not protected health information is included. Both trainings are located within the VA Talent Management System (TMS): https://www.tms.va.gov

What is VA Sensitive Information/Data?

All Department information and/or data on any storage media or in any form or format, which requires protection due to the risk of harm that could result from inadvertent or deliberate disclosure, alteration, or destruction of the information. The term includes not only information that identifies an individual but also other information whose improper use or disclosure could adversely affect the ability of an agency to accomplish its mission, proprietary information, and records about individuals requiring protection under applicable confidentiality provisions.

What is Protected Health Information?

The HIPAA Privacy Rule defines protected health information as Individually Identifiable Health Information transmitted or maintained in any form or medium by a covered entity, such as VHA.

What is an “Incidental” Disclosure?

An incidental disclosure is one where an individual’s information may be disclosed incidentally even though appropriate safeguards are in place. Due to the nature of VA communications and practices, as well as the various environments in which Veterans receive healthcare or other services from VA, the potential exists for a Veteran’s protected health information or VA sensitive information to be disclosed incidentally.

For example:

You overhear a healthcare provider’s conversation with another provider or patient even when the conversation is taken place appropriately.

You may see limited Veteran information on sign-in sheets or white boards within a treating area of the facility.

Hearing a Veteran’s name being called out for an appointment or when the Veteran is being transported/escorted to and from an appointment.

Safeguards You Must Follow To Secure VA Sensitive Information:

Secure any VA sensitive information found in unsecured public areas (parking lot, trash can, or vacated area) until information can be given to your supervisor or Privacy Officer.

You must report such incidents to your Privacy Officer timely.

Don’t take VA sensitive information off facilities grounds without VA permission unless the VA information is general public information, i.e., brochures/pamphlets.

Don’t take pictures using a personal camera without the permission from the Medical Center Director.

Any protected health information overheard or seen in VA should not be discussed or shared with anyone who does not have a need to know the information in the performance of their official job duties, this includes spouses, employers or colleagues.

Do not share VA access cards, keys, or codes to enter the facility.

Immediately report lost or stolen Personal Identity Verification (PIV) or Veteran Health Identification Cards (VHIC), any VA keys or keypad lock codes to your supervisor or VA police.

Do not use a VA computer using another VA employee’s access and password.

Do not ask another VA employee to access your own protected health information. You must request this information in writing from the Release of Information section at your facility.

What are the Six Privacy Laws and Statutes Governing VA?

1. Freedom of Information Act (FOIA) compels disclosure of reasonably described VA records or a reasonably segregated portion of the records to any person upon written request unless one or more of the nine exemptions apply.

2. Privacy Act of 1974 provides for the confidentiality of personal information about a living individual who is a United States citizen or an alien lawfully admitted to U.S. and whose information is retrieved by the individual’s name or other unique identifier, e.g.

Social Security Number.

3. Health Insurance Portability and Accountability Act (HIPAA) provides for the improvement of the efficiency and effectiveness of health care systems by encouraging the development of health information systems through the establishment of standards and requirements for the electronic transmission, privacy, and security of certain health information.

4. 38 U.S.C. 5701 provides for the confidentiality of all VA patient and claimant information, with special protection for their names and home addresses.

5. 38 U.S.C. 7332 provides for the confidentiality of drug abuse, alcoholism and alcohol abuse, infection with the human immunodeficiency virus (HIV) and sickle cell anemia medical records and health information.

6. 38 U.S.C. 5705 provides for the confidentiality of designated medical-quality assurance documents.

What are the Privacy Rules Concerning Use and Disclosure?

You are not authorized to use or disclose protected health information. In general, VHA personnel may only use information for purposes of treatment, payment or healthcare operations when they have a need-to-know in the course of their official job duties. VHA may only disclose protected health information upon written request by the individual who is the subject of the information or as authorized by law.

How is Privacy Enforced?

There are both civil and criminal penalties, including monetary penalties that may be imposed if a privacy violation has taken place. Any willful negligent or intentional violation of an individual’s privacy by VA personnel, contract staff, volunteers, or others may result in such corrective action as deemed appropriate by VA including the potential loss of employment, contract, or volunteer status.

Know your VA/VHA Privacy Officer and Information Security Officer. These are the individuals to whom you can report any potential violation of protected health information or VA sensitive information, or any other concerns regarding privacy of VA sensitive information.

YOU ARE RESPONSIBLE FOR PROTECTING THE CONFIDENTIAL

INFORMATION OF OUR VETERANS

(Print Name) Date

Signature

Print Name of Contract Agency

Print Name of VHA Contracting Officer

PROVIDE A COPY OF THIS FORM TO YOUR CONTRACTING OFFICER

REPRESENTATIVE.

RECORDS MANAGEMENT OBLIGATIONS

1. APPLICABILITY

This clause applies to all Contractors whose employees create, work with, or otherwise handle Federal records, as defined in Section B, regardless of the medium in which the record exists.

2. DEFINITIONS

“Federal Record” as defined in 44 U.S.C. § 3301, includes all recorded information, regardless of form or characteristics, made or received by a Federal agency 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 United States Government or because of the informational value of data in them.

The term Federal record:

a. includes Department of Veterans Affairs, Veterans Health Administration records.

b. does not include personal materials.

c. applies to records created, received, or maintained by Contractors pursuant to their Department of Veterans Affairs, Veterans Health Administration contract.

d. may include deliverables and documentation associated with deliverables.

3. REQUIREMENTS

a. Contractor shall comply with all applicable records management laws and regulations, as well as National Archives and Records Administration (NARA) records policies, including but not limited to the Federal Records Act (44 U.S.C. chs. 21, 29, 31, 33), NARA regulations at 36 CFR Chapter XII Subchapter B, and those policies associated with the safeguarding of records covered by the Privacy Act of 1974 (5 U.S.C. 552a). These policies include the preservation of all records, regardless of form or characteristics, mode of transmission, or state of completion.

b. In accordance with 36 CFR 1222.32, all data created for Government use and delivered to, or falling under the legal control of, the Government are Federal records subject to the provisions of 44 U.S.C. chapters 21, 29, 31, and 33, the Freedom of Information Act (FOIA) (5 U.S.C. 552), as amended, and the Privacy Act of 1974 (5 U.S.C. 552a), as amended and must be managed and scheduled for disposition only as permitted by statute or regulation.

c. In accordance with 36 CFR 1222.32, Contractor shall maintain all records created for Government use or created in the course of performing the contract and/or delivered to, or under the legal control of the Government and must be managed in accordance with Federal law. Electronic records and associated metadata must be accompanied by sufficient technical documentation to permit understanding and use of the records and data.

d. John J. Pershing VA Medical Center and its contractors are responsible for preventing the alienation or unauthorized destruction of records, including all forms of mutilation. Records may not be removed from the legal custody of John J. Pershing VA Medical Center or destroyed except for in accordance with the provisions of the agency records schedules and with the written concurrence of the Head of the Contracting Activity. Willful and unlawful destruction, damage or alienation of Federal records is subject to the fines and penalties imposed by 18 U.S.C. 2701.

In the event of any unlawful or accidental removal, defacing, alteration, or destruction of records, Contractor must report to John J. Pershing VA Medical Center. The agency must report promptly to NARA in accordance with 36 CFR 1230.

e. The Contractor shall immediately notify the appropriate Contracting Officer upon discovery of any inadvertent or unauthorized disclosures of information, data, documentary materials, records or equipment. Disclosure of non-public information is limited to authorized personnel with a need-to-know as described in the [contract vehicle]. The Contractor shall ensure that the appropriate personnel, administrative, technical, and physical safeguards are established to ensure the security and confidentiality of this information, data, documentary material, records and/or equipment is properly protected. The Contractor shall not remove material from Government facilities or systems, or facilities or systems operated or maintained on the Government’s behalf, without the express written permission of the Head of the Contracting Activity. When information, data, documentary material, records and/or equipment is no longer required, it shall be returned to John J. Pershing VA Medical Center’s control or the Contractor must hold it until otherwise directed. Items returned to the Government shall be hand carried, mailed, emailed, or securely electronically transmitted to the Contracting Officer or address prescribed in the contract. Destruction of records is EXPRESSLY PROHIBITED unless in accordance with Paragraph (4).

f. The Contractor is required to obtain the Contracting Officer's approval prior to engaging in any contractual relationship (sub-contractor) in support of this contract requiring the disclosure of information, documentary material and/or records generated under, or relating to, contracts. The Contractor (and any sub-contractor) is required to abide by Government and John J. Pershing VA Medical Center’s guidance for protecting sensitive, proprietary information, classified, and controlled unclassified information.

g. The Contractor shall only use Government IT equipment for purposes specifically tied to or authorized by the contract and in accordance with John J. Pershing VA Medical Center’s policy.

h. The Contractor shall not create or maintain any records containing any non-public John J. Pershing VA Medical Center’s information that are not specifically tied to or authorized by the contract.

i. The Contractor shall not retain, use, sell, or disseminate copies of any deliverable that contains information covered by the Privacy Act of 1974 or that which is generally protected from public disclosure by an exemption to the Freedom of Information Act.

j. The John J. Pershing VA Medical Center owns the rights to all data and records produced as part of this contract. All deliverables under the contract are the property of the U.S. Government for which John J. Pershing VA Medical Center shall have unlimited rights to use, dispose of, or disclose such data contained therein as it determines to be in the public interest. Any Contractor rights in the data or deliverables must be identified as required by FAR 52.227-11 through FAR 52.227-20.

k. Training. All Contractor employees assigned to this contract who create, work with, or otherwise handle records are required to take VHA-provided records management training. The Contractor is responsible for confirming training has been completed according to agency policies, including initial training and any annual or refresher training.

4. FLOWDOWN OF REQUIREMENTS TO SUBCONTRACTORS

a. The Contractor shall incorporate the substance of this clause, its terms and requirements including this paragraph, in all subcontracts under this contract, and require written subcontractor acknowledgment of same.

b. Violation by a subcontractor of any provision set forth in this clause will be attributed to the Contractor.

Records Management for Ever

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Th e w ay fe de ra lr ec or ds ar e m an ag ed ca n be ne fit or da m ag e— m ill io ns of pe op le

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Th e Ge ne ra lS er vi ce s

Ad m in ist ra tio n en su re st ha tf ed er al ag en ci es m an ag e re co rd se co no m ic al ly an d ef fic ie nt ly.

ill fu lly vi ol at in g or fa ili ng to co m pl y w ith la w st ha tg ov er n fe de ra lr ec or ds m an ag em en t an d pr iv ac y an d in fo rm at io n se cu rit y ca n re su lt in ci vi lo rc rim in al pe na lti es .Y ou ca n av oi d pe na lti es by ap pl yi ng w ha ty ou le ar n fr om th is co ur se w he n yo u co m e in co nt ac tw ith fe de ra lr ec or ds ho se jo b is it to m an ag e fe de ra lr ec or ds Ev er yo ne w ho w or ks fo rt he fe de ra l go ve rn m en ti n an y ca pa ci ty ,w he th er as an em pl oy ee ,v ol un te er ,o rc on tr ac to r, ne ed st o kn ow an d un de rs ta nd th e ge ne ra lr eq ui re m en ts an d pr in ci pl es of re co rd sm an ag em

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,m ap s, ph ot og ra ph s, or ot he rp hy sic al ty pe or fo rm

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ro ut in el y ar ch iv es al le m ai lt ra ffi c;

ho w ev er ,e m ai la cc ou nt sf or ce rt ai n us er sd es ig na te d as Ca ps to ne

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bu sin es s is co ns id er ed an of fic ia lr ec or d;

pe rs on al em ai ls ar e no to ffi ci al re co al le m ai lm es sa ge sa re re co rd s.

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Re so ur ce

Al m pl oy ee ss ho ul d un de rs ta nd ho w to te ll th e di ffe re nc e be tw ee n re co rd sa nd no nr ec or ds to pr ev en tm ish an dl in g or in ap pr op ria te de st ru ct io n.

If yo u ar e un su re w he th er so m et hi ng is a re co rd or a no nr ec or d, tr ea ti ta sa re co rd an d co ns ul ty ou rR ec or ds

O ffi r.

He ar e ty pe so fn on re co

Pe rs on al fil es m us tb e ke pt se pa ra te fr om re co rd so ra ny ot he ra ge nc y bu sin es s in fo rm at io n.

He re ar e so m e ex am pl es of pe rs on al fil

Ge ne ra lly ,o ffi ce st ha tc re at e th e re co rd m us tm ak e th ei ro w n de te rm in at io ns w he th er or no tt o in co rp or at e w or ki ng fil es in to th e re co

Do cu m en ta ry m at er ia ls ar e re co rd sw he n th ey m ee tb ot h of th es e cr ite ria (1 )T he y w er e m ad e or re ce iv ed by a fe de ra lg ov er nm en ta ge nc y w hi le co nd uc tin g bu sin es s.

(2 )T he y ar e ap pr op ria te fo rp re se rv at io n ei th er as ev id en ce of th e ag en cy 's or ga ni za tio n, fu nc tio ns ,a nd ac tiv iti es or be ca us e of th e va lu e of th e in fo rm at io n th ey co nt ai n.

st at em en ti sf al se .W hi le al lV A em ai lm es sa ge sa re ar ch iv ed as el ec tr on ic re co rd s, pe rs on al em ai ls th at do no tc on ta in of fic ia lb us in es sa re no tc on sid er ed of fic ia lr ec or ds an d ar e no tt ra ns fe rr ed to N rd sa nd no nr ec or ds ar e bo th ty pe so fb us in es si nf or m at io n, an d bo th ar e

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pr op er ty

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A bu sin

Yo u sh ou ld no w un de rs ta nd th e le ga ld ef in iti on of re co rd sa nd be ab le to re co gn ize th e di ffe re nc e be tw ee n re co rd sa nd no nr ec or ds .R ev ie w th es e ke y te rm sb ef or e yo u m ov e to th e ne xt le ss on

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re co rd sl ife cy cl e he lp si de nt ify th e or de ro ft as ks th at m us tb e co m pl et ed to m an ag e re co

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Af te rm at er ia lh as be en id en tif ie d as a re co rd an d sc he du le d, it m us tb e m ai nt ai ne d an d di sp os ed of ac co rd in g to th e ap pr ov ed sc he du le an d re la te d N

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,i nd ic at es w he th er re co rd sa re te m po ra ry or pe rm an en t.

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.I ta lso co nt ai ns in st ru ct io ns fo rd isp os iti on of re co

Fi pl an sa re an es se nt ia lc om po ne nt of th e re co rd ke ep in g sy st em an d ar e im po rt an tf or su cc es sf ul re co rd sm an ag em re te nt io n pe rio d is th e re qu ire d le ng th of tim e te m po ra ry re co rd sm us tb e re ta in ed

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Th e

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O ffi ce of Ge ne ra lC ou ns el m ay im pl em en ta lit ig at io n ho ld on re co rd st ha ta re in

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’s cu st od y.

Be ve ry ca re fu ln ot to de st ro y or tr an sf er an y re co rd s su bj ec tt o a lit ig at io n ho ld .N ot e:

Re co rd st ha th av e m et th ei r d isp os iti on an d re te nt io n pe rio d an d ar e st ill in yo ur cu st od y ar e su bj ec tt o th e lit ig at io n ho ld

U se th es e fo rm sa nd fo llo w th es e st ep st o tr an sf er re co rd st o a fe de ra lr ec or ds ce nt er or a

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re co rd sc en te rf or te m po ra ry st or ag

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Re co rd sC en te rV au lt (R

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A st an da rd sa re op tio ns fo rs to rin g re co rd sw he n th ey ar e no tr ea dy fo rd isp os iti on an d ar e no ta ct iv el y be in g us ed

.T he ad m in ist ra tio n or st af fo ffi ce in po ss es sio n of th e re co rd s, in co ns ul ta tio n w ith th e Re co rd s O ffi ce r, m us td ec id e th e m os t co st ef fe ct iv e an d ef fic ie nt op tio co rd ss er ie si sa co nv en ie nt w ay of gr ou pi ng fil e un its or do cu m en ts to pe rm it th ei r m an ag em en ta sa gr ou p.

Th e un it to be in ve nt or ie d is no rm al ly th e re co rd ss er ie s, no t in di vi du al do cu m en ts or fil e fo ld er co rd ss er ie si sa gr ou p of re co rd sa rr an ge d ac co rd in g to a fil in g sy st em or ke pt to ge th er be ca us e th ey ha ve a co m m on su bj ec to rf un ct io n or sim ila rc om m on el em en t.

A re co rd s co nt ro ls ch ed ul e is a do cu m en tt ha tg ov er ns re te nt io n pe rio d an d di sp os iti on

.R et en tio n pe rio d is th e re qu ire d le ng th of tim e te m po ra ry re co rd s m us tb e re ta in ed

Li tig a t io n ho ld sa re a le ga lh ol d th at te m po ra ril y su sp en ds th e N

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A ap pr ov ed re co rd s di sp os iti on au th or ity fo rt he re co e pr oc es se sa re es se nt ia lt o im pl em en tin g a re co rd sp ro gr am

:c on du ct in g th e re co rd s in ve nt or y, cr ea tin g an d up da tin g th e re co rd ss ch ed ul e, an d cr ea tin g an d up da tin g th e fil e pl

Co nd uc tin g a re co rd si nv en to ry ,c re at in g a re co rd sc on tr ol sc he du le ,a nd cr ea tin g a fil e pl an ar e th re e in te rr el at ed pr oc es se sf or m an ag in g re co m us te ns ur e th at th os e w ho ha nd le re co rd sk no w th er e is a sp ec ia lh an dl in g re qu ire d w he n

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se ns iti ve in fo rm at io n is co nt ai ne d in re co

Be aw ar e of ris ks to pr iv ac y an d in fo rm at io n se cu rit y th ro ug ho ut th e re co rd sl ife cy

M ag in g re co rd st hr ou gh ou tt he ir lif e cy cl e re qu ire sa n un de rs ta nd in g of th e ke y te rm s an d co nc ep ts di sc us se d in th is le ss on

.R ev ie w th es e ke y te rm sb ef or e yo u m ov e to th e ne xt le ss on

.B e su re to un de rs ta nd th es e ke y te rm sb ef or e ad va nc in g to th e ne xt le ss

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Active records are used to conduct current business and are maintained in office space and equipment (including virtual locations).

Administration and staff office chiefs (Under Secretaries, Assistant Secretaries, and other key officials) control and organize records programs for their organizations.

Each leader must designate a Records Officer and must ensure the records program is implemented. Administration and staff office Records Officers create records management practices to support the business functions in their organizations. They work with the VA Records Officer to ensure each program is consistent with VA-wide requirements.

Administration and staff office Records Officers conduct regular internal records management reviews to ensure appropriate procedures are being followed.

Appropriate for preservation means suitable for filing, storage, or other systematic maintenance by the agency, regardless of any inadequacies in the agency’s formal recordkeeping policies and practices.

Capstone Officials are VA officials regardless of grade who are generally responsible for agency and program policy- and mission-related actions. Capstone officials vary agency by agency depending on an agency’s organization and how it carries out agency roles. If you have been identified as a Capstone Official, all of your email records containing official VA business are considered permanent and must be preserved for transfer to NARA at some future date. To avoid mixing personal emails with Federal email records, it is essential that all VA employees, regardless of their Capstone status, sort through their emails manually removing emails that are strictly personal. This process is referred to as culling.

VA maintains the legal and physical custody of the electronic email accounts of Capstone Officials for a 15-year period and then transfers the legal and physical custody to NARA for historical preservation.

Control and organization is the first records program component and is the foundation for other components. The Secretary of VA has ultimate responsibility for ensuring the program is implemented and complies with all requirements.

Convey NARA bulletins NARA issues NARA bulletins to federal agencies to provide guidance and assistance on the management and disposition of federal records, such as:

2017-01: Agency Records Management Training Requirements 2016-01: Guidance on NARA Bulletin Expiration Dates 2015-04: Metadata Guidance for the Transfer of Permanent Electronic Records 2015-03: Guidance on Managing Digital Identity Authentication Records 2015-02: Guidance on Managing Electronic Messages 2015-01: Scheduling Guidance on the Appropriate Age for Legal Transfer of Permanent Records to the National Archives of the United States

Cutoff date - It is recommended to cutoff or break records in a series or system at regular intervals, usually annually. This permits their disposal or transfer in complete blocks and to permit the establishment of new files. For example, it is fairly typical at the end of a fiscal year to remove last year's chronological correspondence file.

Designated Records Management Official - A person designated to serve as the records officer for an organization, with oversight responsibilities for the management, retention, and disposition of VA records for his or her respective organization, to include Central Office program offices and respective field facilities that fall under their purview. Note that the title of this official may vary from one organization to the next.

Other titles include but are not limited to Records Officer, Records Liaison Officer, Records Management Officer, Records Management Technician, and Records and Information Management Specialist. This designated official works in cooperation and coordination with the VA Records Officer.

Destroying or Removing Records Federal employees may be subject to disciplinary and adverse actions for destroying or removing records without proper authorization. Read more about these penalties in VA Handbook 5021, Employee Management Relations Part 1, Appendix A Range of Penalties:

Item 11: Failure to safeguard confidential matter Item 26: Loss of, damage to, or unauthorized use of government property

Disposal - 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 a waste material, or other forms of salvage or transfer.

This includes erasure of information captured or maintained on electronic media.

Disposition - An interim or final placement of records and recorded information; the actions taken with regard to records and recorded information to maintain them in a proper place following their appraisal, including 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.

Disposition authority - The legal authorization obtained only from the archivist of the United States, NARA, for the disposal of records and recorded information.

Documentary materials is a collective term that refers to all media on which information is recorded, regardless of the nature of the medium or the method or circumstances of recording. The term usually refers to records and nonrecord materials, but it may also include personal files.

Electronic records - 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, which requires the use of specialized equipment to convert the information to human-readable form.

Facility Records Officers evaluate the facility records program regularly.

Records Liaisons support Facility Records Officer reviews.

Federal Information Security Modernization Act (FISMA) - Title 3 of the E-Government Act of 2002, Pub. L. 107-347 (Dec. 17, 2002)

Inactive records are not needed for current business and are generally maintained in off-site storage such as, the Records Center Vault (RCV) at Neosho, Missouri or leased commercial space.

Information security - A means for protecting VA information and information systems from unauthorized access, use, disclosure, disruption, modification, or destruction in order to provide integrity, confidentiality, and availability.

Information Security Officer (ISO) - Individual responsible to the Senior Agency Information Security Officer, authorizing official, or information system owner for ensuring the appropriate operational security posture is maintained for an information system or program.

Information systems - Discrete sets of information resources including all records, information, information handling functions, and systematic processes organized for the collection, processing, maintenance, use, sharing, dissemination, or disposition of information, whether automated or manual.

Made means the act of creating and recording information by agency employees, regardless of the method or medium involved. Such recorded information is generally circulated to others or placed in files accessible to others.

Managing Government Records Directive M-12-18 This directive was issued in 2011 and requires:

• By 2016, VA must manage all email records in an electronic format

• By 2019, all permanent electronic records in VA must be managed electronically for eventual transfer and accessioning by the National Archives and Records Administration (NARA) in an electronic format.

Managing records effectively ensures that permanently valuable records become part of the National Archives and Records Administration (NARA) while other records and information of temporary value are retained for as long as needed and then properly disposed. In addition, the heads of federal agencies must issue instructions to staff on the identification, management, retention, and disposition of email messages determined to be federal records (36 CFR 1236.22(a). The Agency must notify employees that there are criminal penalties for the unlawful removal or destruction of federal records (18 U.S.C. 2071 and 36 CFR 1230.12) and the unlawful disclosure of national security information (18 U.S.C. 793, 794, and 798).

A records series could include file units or items arranged in accordance with a filing system. They could also be maintained as a unit because they result from the same accumulation or filing process, relate to a particular subject or function, or a product of the same activity; have a particular physical form; or because of some other relationship arising out of their creation, receipt, or use.

For example, each VA Administration has an RCS that denotes the retention and disposition requirements for their particular records (i.e., by section):

•National Cemetery Administration (NCA): Burial Records •Veterans Benefits Administration (VBA): Claims Folders, Loan Guaranty Records •Veterans Health Administration (VHA): Environmental Agents Service, Health

Eligibility Center Records, Health Information Management Service, Laboratory Service

Non-Capstone Officials are employees and contractors who are not captured as a Capstone official. These email records will be retained for a period of 7 years and then deleted.

NOTE: Depending on an individual’s role within the organization, email records may be maintained longer than the 7-year retention period. These email records will be identified and additional retention periods may be applied to satisfy the business need.

Nonrecords - All informational materials that are determined to be disposable by VA without the specific approval of the archivist of the U.S. and that are not included within the definition of "record material." (See also: VA Handbook 6300.1, Appendix A)

Permanent records - Records and information appraised by VA and approved by NARA as having enduring value because they document the organization and functions of the agency that created or received them and/or because they contain significant information on persons, things, problems, and conditions with which VA dealt, and for which there is no plan for destruction.

Preserved means the filing, storing, or any other method of systematically maintaining documentary materials by the agency, even if those materials have not yet been filed or have been removed temporarily from existing filing systems.

Personally Identifiable Information (PII) - Any information which can be used to distinguish or trace an individual's identity, such as their name, social security number, biometric records, etc. alone, or when combined with other personal or identifying information which is linked or linkable to a specific individual, such as date and place of birth, mother's maiden name, etc. Information does not have to be retrieved by any specific individual or unique identifier (i.e., covered by the Privacy Act) to be personally identifiable information. Source: Office of Management and Budget (OMB) Memorandum 07-16, Safeguarding Against and Responding to Breaches of Personally Identifiable Information (May 22, 2007).

Privacy Officer (PO) - The PO is responsible for taking proactive measures to help ensure that PII collected by VA is limited to that which is legally authorized and necessary; and is maintained in a manner that precludes unwarranted intrusions upon individual privacy, thereby minimizing privacy events. Additionally, it is the defensive duty of a PO to assist in mitigating damage when PII is compromised. SOURCE: VA Directive 6509

Prohibited actions can have serious consequences including civil and criminal penalties. Prohibited actions include:

Willfully destroying records or violating the Privacy Act Removal of records from VA premises without authorization Destruction of records in accordance with the disposition requirements in the

RCS

The combining of personal files with official records

Promotion - Promotion is "encouragement of the progress, growth, or acceptance of something; furtherance. Advertising; publicity." Promotion is more than just publicity.

It is not one promotional item or event, but a process. Promoting, along with planning, controlling, directing, organizing, and training, are managerial activities involved with records management. Federal agencies are required to promote the elements within their records management program. They should use promotional materials and activities to advertise (and support) the training related to records management, as well as the records management program itself. Source: NARA training, Records Management Program Development.

Protection- Safeguards to reduce risk are called Security controls. The greater the perceived risk, the more stringent the safeguards must be. For example, if no access controls existed, anyone could open a Veteran's medical or claims record and make changes.

Received means the acceptance or collection of documentary materials by agency employees (regardless of who originated the materials), whether employees within the agency or in other agencies or whether private citizens, government grantees, or others;

regardless of how the materials were transmitted, whether directly by the originator or indirectly by messenger, mail, electronic means, or some other method. In this context, the term received does not refer to misdirected materials. It may or may not refer to loaned or seized materials. The question of government ownership of loaned or seized materials depends on the conditions of agency custody for use and should be referred to legal counsel for advice.

Records - 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 U.S. 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. Source: Federal Records Act (44 U.S.C. 3301)

Records appraisal - 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 federal agencies, or to the general public.

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.

Records life cycle - The management concept that records pass through three stages:

creation and receipt, maintenance and use, and disposition.

Records management - The managerial activities involved with respect to records creation and receipt, maintenance and use, and disposition of records to achieve adequate and proper documentation of the policies and transactions of the federal government and effective and economical management of VA operations.

Records Officer - Persons designated responsible for managing and…