36C25520Q0040-004.pdf

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Department of Veterans Affairs Veterans Health Administration Washington, DC 20420

VHA DIRECTIVE 6300

Transmittal Sheet October 22, 2018

RECORDS MANAGEMENT

1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive establishes authority, policy, and procedures for a formalized VHA records management program within all VHA organizational components. This is in response to Department of Veterans Affairs (VA) policy and mandates of the National Archives and Records Administration (NARA).

2. SUMMARY OF MAJOR CHANGES: This directive defines the policy and procedures 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, Records and Information Management, dated February 26, 2009; VA Handbook 6300.1, Records Management Procedures , dated March 24, 2010; VA Handbook 6300.2, Management of the Vital Records Program, dated January 12, 1998; VA Handbook 6300.8, Procedures for Shipment of Records to the VA, dated January 12, 1998; VA Directive 6301, Electronic Mail Records, dated April 24, 1997; VA Handbook 6301, dated April 24, 1997; Procedures for Handling Electronic Mail Records, dated VA Directive 6371, Destruction of Temporary Paper Records, dated April 8, 2014; VA Directive 6500, Managing Information Security Risk: VA Information Security Program, dated September 20, 2012;

VA Handbook 6500.1 Electronic Media Sanitization, dated November 3, 2018; VHA Directive 0320.01, VHA Comprehensive Emergency Management Program (CEMP) Procedures, dated April 6, 2017; and VHA Directive 6300.01, Records Management Compliance Monitoring, dated August 17, 2017; or subsequent policies.

4. RESPONSIBLE OFFICE: The VHA Office of Informatics and Information Governance (OIIG), Health Information Governance (HIG), Health Information Management (HIM) Program Office, Records Officer (10A7), are responsible for the contents of this directive. Questions may be referred to the VHA Records Officer at 202-461-5509.

5. RESCISSIONS: VHA Directive 6300, dated July 10, 2012, is rescinded.

6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of October 2023. This VHA directive will continue to serve as national VHA policy until it is recertified or rescinded.

http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=56 http://www1.va.gov/vapubs/viewPublication.asp?Pub_ID=56

October 22, 2018 VHA DIRECTIVE 6300

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Richard A. Stone, M.D.

Executive in Charge

NOTE: All references herein to VA and VHA documents incorporate by reference subsequent VA and VHA documents on the same or similar subject matter.

DISTRIBUTION: Emailed to VHA Publications Distribution List on October 24, 2018.

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CONTENTS

RECORDS MANAGEMENT

1. PURPOSE

2. BACKGROUND

3. DEFINITIONS

4. POLICY

5. RESPONSIBILITIES

6. MAINTAINING AND USING RECORDS AND INFORMATION

7. FILE MANAGEMENT

8. RECORDS DISPOSITION PROGRAM

9. TYPES OF RECORDS

10. SUBMISSION AND APPROVAL OF REQUESTS FOR DISPOSITION AUTHORITY

11. TRANSFER OR LOAN OF VHA RECORDS

12. TRAINING

13. RECORDS STORAGE

14. RECORDS FREEZES/HOLDS

15. MANAGEMENT OF RECORDS FOR TELEWORK PERSONNEL

16. REFERENCES

APPENDIX A

SENIOR LEADER AND DEPARTING OFFICIAL RECORDS REQUIREMENTS..A-1

APPENDIX B

REPORTING INTENTIONAL OR ACCIDENTAL LOSS OR DAMAGE OF RECORDS

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RECORDS MANAGEMENT

1. PURPOSE

This Veterans Health Administration (VHA) directive is issued to provide basic requirements for the establishment and maintenance of a formalized records management program within all VHA organizational components. AUTHORITY: Title 36 Code of Federal Regulations (CFR) Chapter XII, Subchapter B.

2. BACKGROUND

VHA, by Federal statute and regulation, must establish and maintain a formal records management program encompassing all Federal records, in paper, electronic, or other medium, in accordance with the National Archives and Records Administration (NARA)-requirements, NARA General Records Schedule (GRS), and NARA-approved VHA record disposition schedules. Records must be managed from their creation to final disposition.

3. DEFINITIONS

a. Audiovisual Records. Records in pictorial or aural 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. Computer Matching Program. A computer matching program is any computerized comparison of two or more automated systems of records. A matching program covers the actual computerized comparison and any investigative follow-up and ultimate action. Only matching programs involving Federal benefits programs and matches using records from Federal personnel or payroll systems of records are applicable to the procedures in this directive. Legal questions regarding whether a proposed computer data exchange meets the standards for a matching program should be referred to the Office of the General Counsel (OGC) Professional Staff Group (PSG) IV (024), or successor office.

c. 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 waste material, or other forms of salvage or transfer; includes erasure of information captured or maintained on electronic media.

d. 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.

The list of VHA dispositions can be found in Record Control Schedule (RCS) 10-1.

e. Electronic Mail Records. Senders’ and recipients’ versions of electronic mail messages that meet the definition of Federal records, and any attachments to the record messages after they have been copied to an electronic recordkeeping system, paper, or microform for recordkeeping purposes. (For further information, see paragraph 9.d.)

f. Electronic Records. Electronic, or machine-readable records, are records on electronic storage media. Electronic record, as defined in NARA regulations (36 CFR 1234.2), means any information that is recorded in a form that only a computer can process and that satisfies the definition of a Federal record per the Federal Records Act. Federal electronic records are not necessarily kept in a "recordkeeping system" but may reside in a generic electronic information system or are produced by an application such as word processing or electronic mail.

g. Information System. The aggregate of all records, information, information handling functions, and systematic processes necessary for operating a program; the organized collection, processing, transmission, and dissemination of information in accordance with defined procedures, whether automated or manual.

h. Life Cycle of Records. The management concept that records pass through three stages: creation, maintenance and use, and disposition.

i. Microform Records. Microforms are any forms, either films or paper, containing micro-reproduction of records for transmission, storage, reading, and printing.

Microform images are commonly reduced to about one twenty-fifth of the original document size. For special purposes, greater optical reductions may be used. All microform images may be provided as positives or negatives, more often the latter.

Microform records are records on any form containing greatly reduced images, normally on microfilm. Three formats are common: microfilm (reels), aperture cards, and microfiche (flat sheets).

j. Non-record Material. All informational materials which are determined to be disposable by VA without the specific approval of the Archivist of the United States which are not included within the definition of “Record Material”. Specifically, this includes informational materials preserved solely for purposes of reference; extra copies of documents preserved only for convenience of reference (reading file and follow-up copies of correspondence, identical copies of documents maintained in the same file, extra copies of printed or processed materials of which official copies have been retained for purposes of record, etc.); stocks of publications and processed documents preserved for supply purposes; drafts, worksheets, and notes that do not represent significant basic steps in the preparation of record copies of documents, that were not circulated or made available to employees other than the creator, and that do not contain unique information that aids in the understanding of VA business that has not been made part of the official record; letters of transmittal that do not add information to that contained in the transmittal material; shorthand notes, stenotype tapes and similar secretarial materials, such as word processing disks/diskettes from which the informational content has been transcribed or otherwise processed to provide official copies for purposes of record; and other material that has been determined to be non-record based on the appraisal procedures.

k. Permanent Records and Information. Permanent (archival) records are defined as records that have been appraised by VA and NARA and approved by NARA to have sufficient historical value or other value to warrant permanent preservation at the National Archives. Those records that have enduring historical or other value and will never be removed from Federal custody. In United States Government usage, 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. (For further information, see paragraph 8.a.)

l. Personal Papers. are documentary material of a private or non-public character that do not relate to or have an effect on the conduct of Veteran Affairs, Veteran Health Administration, or general government business.

m. Records (Federal). Records include all records 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. (44 U.S.C.

Chapter 33, Sec. 3301).

n. 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 agencies of the Federal Government, or to the general public.

o. Records Liaison. Service line representative who works in conjunction with the Records Manager to ensure proper management of records created and maintained by the service line.

p. Records Management. The managerial activities involved with respect to records creation, 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.

q. Records Manager. Persons designated responsibility for managing and coordinating a records management program for their respective organization.

r. Records Officer (VHA). The person assigned responsibility by the agency head for overseeing an agency-wide records management program.

s. Records Series. File units or records arranged according to a filing system or kept together because they relate to a particular subject or function, result from the same activity, document a specific kind of transaction, take a particular physical form, or have some other relationship arising out of their creation, receipt, or use, such as restrictions on access and use.

t. Temporary Records. Temporary records are records which will be destroyed or otherwise removed from Federal Government control after a fixed period of time or after occurrence of a specified event, and records approved by NARA for disposal, either immediately or after a specified retention period. (For further information, see paragraph 9.b.)

u. Unscheduled Records. Records that have not been evaluated to determine their record retention value, i.e., retention and disposition standards. Such records are to be retained until they receive disposition authorities from NARA. Records whose final disposition has not been approved by NARA. (See also paragraph 9.c.)

v. Vital/Essential Records. Records essential for maintaining the Continuity of Operations during and following a national or regional emergency.

4. POLICY

It is VHA policy to manage, maintain, and dispose of official records in accordance with established records management statutes, regulations, policies, practices, and procedures, and pursuant to current NARA-approved VHA records disposition schedules as outlined in VHA Records Control Schedule 10-1.

5. RESPONSIBILITIES

a. Under Secretary for Health. The Under Secretary for Health is responsible for oversight of this directive, to include:

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

(2) Ensuring a vital/essential records program is maintained to guarantee the continuity of essential Federal government operations 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 scheduled and their approved retention periods published in the Records Control Schedule (RCS) 10-1.

(4) Ensuring the Records Program Office is placed at a level in VHA with sufficient authority and funding to efficiently and effectively implement the objectives and policies of the VHA records management program.

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

b. VHA Records Officer. The VHA Records Officer 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 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) Coordinating with the VHA Privacy Compliance Assurance (PCA) Office on the criteria for how VHA facilities will be monitored, what level of monitoring will be conducted, content of compliance monitoring Facility Self-Assessment (FSA) surveys and other operational decisions that impact the monitoring functions outlined VHA policy.

(8) Approve the transfer to NARA of permanent records submitted for such transfer by Program Office Records Coordinators and Facility Records Managers.

c. Senior Executive Service (SES). Senior Executive Service (SES) personnel are responsible for:

(1) 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.

(2) Ensuring their program office and other areas under their control meet all requirements for the creation, maintenance, use, storage, and disposition of Federal records generated or obtained within their operations, i.e., the lifecycle of records under RCS 10-1 or the General Record Schedule (GRS).

(3) Ensuring that any records creating organizational policy, research, or responses to Congress are controlled and maintained in accordance with RCS 10-1 or the GRS.

NOTE: Due to the level of responsibility, SES personnel may be creating permanent https://www.tms.va.gov/

VHA records. Care should be taken that these individuals’ work-products and e-mails are maintained per RCS 10-1 or the GRS.

d. VHA Program Chief Officer. The VHA Program Chief Officer is responsible for:

(1) Designating Program Office Records Coordinator(s) to coordinate and oversee the records management program. NOTE: This may include assignment of more than one Program Office Records Coordinator for program offices depending on the complexity of the program and the management of multiple physical locations.

(2) Ensuring Program Office Records Coordinators are appointed to a level within the organization with sufficient authority to efficiently and effectively implement the objectives and policies of the VHA records management program.

(3) Ensuring VHA records management program goals are adhered to in accordance with VA/VHA Records Management Policy, RCS 10-1 and GRS record schedules.

NOTE: The VHA Program Chief Officer has differing responsibilities for records created by teleworkers, depending on the teleworker’s location. These responsibilities are specified in paragraph 15.

e. VHA Program Office Records Coordinators. The VHA Program Office Records Coordinator is responsible for:

(1) Implementing policy and procedures for administering their individual Program Office records management program.

(2) Completing the VA Talent Management System (TMS) course, “Records Management for Records Officers and Liaisons” annually and other required records management training as directed, 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.

Additional VHA training for Records Managers is available at https://myees.lrn.va.gov/default.aspx; this is an internal VA Web site which is not available to the public.

(3) Ensuring all employees within their program office 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.

(4) Developing standardized File Plans and indexing approaches, where appropriate, to simplify the use, access, and integration of information within the Program Office.

(5) Maintaining, reviewing, and managing the Program Office’s Records Inventory/File Plan and providing updates to the VHA Records Management Office, at least annually.

https://www.tms.va.gov/ https://myees.lrn.va.gov/default.aspx

(6) Implementing approved records dispositions and ensuring records are not destroyed without proper authorization, as specified in RCS 10-1 or GRS.

(7) Contacting the VHA Records Management Office when unscheduled records are discovered within the Program Office.

(8) Conducting regular internal records management reviews to assist with the implementation of appropriate records management procedures within their Program Office in accordance with VHA Handbook 1605.03, Privacy Compliance Assurance Program and Privacy Compliance Monitoring, dated April 13, 2009, and VHA Directive 6300.01, Records Management Compliance Monitoring, dated August 17, 2017.

(9) Determining if permanent records are ready for transfer to NARA. (See paragraph 8.e.(5), (6).)

(10) Assisting the VHA Records Management Office in the planning and implementation of automated or manual information systems to ensure that records or information created and generated will be properly scheduled in the VHA RCS 10-1.

(11) Assisting the VHA Records Officer in the implementation of the VHA Vital/Essential Records Program in accordance with the VA-wide program in VA Handbook 6300.2, Management of the Vital Records Program. For more detailed information, see paragraph 9.h.(5).

(12) Apprising Program Management leaders and managers on matters relating to records management activities and requirements impacting the program office.

(13) Providing technical advice to off-site Program Office staff on maintaining an effective records management program.

(14) Ensuring that departing/terminating employees do not remove facility records from VHA custody. Ensure that employees turn over their records to their supervisor or another employee determined by the supervisor.

(15) Reviewing Program Office contracts that create, use, store, and disposition facility records to ensure compliance with 36 CFR 1220.30(c) (1).

(16) Contacting the VHA Records Management Office prior to securing off-site records storage locations and ensuring on-site and off-site locations meet the requirements of 36 CFR 1234, Subpart B, Facility Standards for Records Storage Facilities. Maintaining copies of all transfer and destruction records within the Program Office and providing a copy to the VHA Records Management Office.

(17) Assisting the Office of General Counsel and the VHA Records Officer in the execution of records freeze/litigation holds.

NOTE: The Program Office Records Coordinator is in a unique position to manage records related to policy, operations and mission of VHA. These individuals serve essentially as the Records Manager for a program office in a similar manner to the Records Managers within a VA medical facility. However, since the Program Office can be located in Washington DC at the Veterans Affairs Central Office (VACO) or may be remote in other locations within the United States, the duty of the Records Coordinator is somewhat different than a Records Manager. Also, many Program Offices records have been given the disposition schedule of “Permanent” by NARA. Special attention should be given to any record documenting the policies, transactions and management of official VHA operations and mission. The Program Office should exercise care to manage and maintain these records and ensure permanent records are transferred to NARA as required by RCS 10-1 and GRS records schedules.

NOTE: The VHA Program Office Records Coordinators have differing responsibilities for records created by teleworkers, depending on the teleworker’s location. These responsibilities are specified in paragraph 15.

f. VISN Directors. The VISN Director is responsible for establishing policies and processes in compliance with this directive, to include:

(1) Designating a VISN Records Manager and Alternate Records Manager to coordinate and oversee the VISN records management program. NOTE: Alternate Records Managers must be capable of taking full responsibility for managing the Records Management program in the Records Manager’s absence.

(2) Ensuring that the VISN Records Manager is appointed to a level within the organization with sufficient authority to efficiently and effectively implement the objectives and policies of the VHA records management program.

(3) Ensuring the VISN is in compliance with all provisions of the VHA records management program, to include establishing a VISN Vital/Essential Records Program, maintaining proper storage and accessibility of facility records regardless of medium, and adherence to and disposal of facility records in accordance with approved policies and disposition schedules.

(4) Ensuring the VISN meets all requirements for the creation, maintenance, use, storage, and disposition of Federal Records generated or obtained within their operational control, i. e. the life cycle of records.

g. VA Medical Facility Directors. The VA medical facility Director is responsible for:

(1) Designating a facility Records Manager and Alternate Records Manager to coordinate and oversee the records management program. NOTE: Alternate Records Managers must be capable of taking full responsibility for managing the Records Management program in the Records Manager’s absence.

(2) Ensuring that the facility Records Manager is appointed to a level within the organization with sufficient authority and resources to efficiently and effectively implement the objectives and policies of the VHA records management program.

(3) Ensuring all service lines and Community Based Outpatient Clinics (CBOCs) support the facility Records Manager in all aspects of the facility records management program and designate Records Liaisons to prepare and maintain the service line, or CBOC Records Inventory and File Plan.

(4) Ensuring the facility is in compliance with all provisions of the VHA records management program, to include establishing a facility vital/essential records program.

(5) Ensuring the facility meets all requirements for the creation, maintenance, use, storage, and disposition of Federal Records generated or obtained within their operational control, i. e. the life cycle of records.

(6) Assisting the Office of General Counsel and the VHA Records Officer in the execution of records freeze/litigation holds.

h. Facility Records Managers and/or Alternates. The Facility Records Manager and/or Alternate are responsible for:

(1) Managing and coordinating a records management program for their respective organization. The program goal is to manage federal records throughout their lifecycle (creation, maintenance, use, and disposition).

(2) Implementing policy and procedures for administering the facility records management program and updating as necessary to ensure they are current, relative and comprehensive.

(3) Completing the VA Talent Management System (TMS) course, “Records Management for Records Officers and Liaisons” annually and other required records management training as directed, 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.

Additional VHA training for Records Managers is available at https://myees.lrn.va.gov/default.aspx; this is an internal VA Web site which is not available to the public.

(4) 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.

(5) Implementing approved records dispositions, while ensuring that no records are destroyed without proper authorization as specified in the RCS 10-1 or General Records Schedule (GRS).

(6) Systematically reviewing and updating the facility Master Record Inventory and File Plan at least annually.

(7) Contacting the VHA Records Officer when unscheduled records, regardless of medium, are discovered within the facility. Once the unscheduled record is identified, https://www.tms.va.gov/ the facility Records Manager will protect the unscheduled record from destruction until a new records schedule is approved by NARA. NOTE: Only the VHA Records Officer is authorized to communicate with NARA to create or change a VHA records control schedule; these actions are taken in collaboration with the VHA Program Office who is responsible for the records covered under their program.

(8) Conducting regular internal records management reviews in accordance with VHA Handbook 1605.03, Privacy Compliance Assurance Program and Privacy Compliance Monitoring, dated April 13, 2009; and VHA Directive 6300.01, Records Management Compliance Monitoring, dated August 17, 2017, to assist offices within the facility in implementing appropriate records management procedures.

(9) Serving as advisor to the facility’s Continuity of Operations (COOP) team/Emergency Management Team to assist in the implementation of the COOP/ Emergency Management and the Vital/Essential Records program in accordance with the VA-wide program in VA Handbook 6300.2, Management of the Vital Records Program. For more detailed information on this process, see paragraphs 6.d. and 9.h.(5).

(10) Apprising facility leaders and managers on matters relating to records management activities and requirements and serving as the facility subject-matter expert related to records management activities and requirements.

(11) Developing records management oversight roles and communication networks with all facility service and product lines, programs, and Community Based Outpatient Clinics (CBOCs) to ensure that the records management program is carried out in accordance with this policy.

(12) Providing technical advice and training to Records Liaisons and facility staff on maintaining an effective records management program.

(13) Determining if permanent records are ready for transfer to NARA. (See paragraph 8.e.(5), (6).)

(14) Ensuring that departing/terminating employees do not remove facility records from VHA custody and that they transfer custody of the records to the appropriate employee or office prior to being cleared.

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

(16) Ensuring all inactive record storage locations meet the requirements of 36 CFR 1234, Subpart B, “Facility Standards for Records Storage Facilities.” (See paragraph 13.b.)

(17) Collaborating with the facility Privacy Officer in the identification of systems requiring a new System of Records Notification (SORN) ensuring that the correct records disposition is used.

(18) Assisting the Office of General Counsel, facility Director and the VHA Records Officer in the execution of records freeze/litigation holds.

(19) Upon designation as Records Manager/Program Office Coordinator, reviewing Appendix A, Senior Leader and Departing Official Records Requirements of this directive.

(20) Report loss, destruction, or damage to Federal records to the facility Director as required by 36 CFR 1230.

NOTE: The Facility Records Manager has differing responsibilities for records created by teleworkers, depending on the teleworker’s location. These responsibilities are specified in paragraph 15.

NOTE: Many of the day-to-day operational requirements of facility records management can be found in Appendix B.

i. Service Chiefs, Program Supervisors or Managers. The Service Chiefs, 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 is 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 Facility Records Manager concerning records management problems or concerns.

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

NOTE: Service Chiefs, Program Supervisors, and Managers have differing responsibilities for records created by teleworkers, depending on the teleworker’s location. These responsibilities are specified in paragraph 15.

j. Records Liaisons. The Record Liaisons are responsible for:

(1) Working in conjunction with the facility Records Manager to ensure full and proper implementation of the records management program within their respective area.

(2) Maintaining, reviewing and managing their respective service line, program offices, or CBOCs Records Inventory and File Plan and providing updates to the facility Records Manager, at least annually. (For further details, see paragraph 7.d.)

(3) Completing the VA Talent Management System (TMS) course, “Records Management for Records Officers and Liaisons” annually and other required records management training as directed (see paragraph 12.b), 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. Additional VHA training for Records Liaisons is available at:

https://myees.lrn.va.gov/default.aspx; this is an internal VA Web site which is not available to the public.

(4) Reporting the accidental/unauthorized destruction or catastrophic loss of facility records to their immediate supervisor and the facility Records Manager in a timely manner. (See 36 CFR 1230.)

(5) Contacting the facility Records Manager when unscheduled records in any medium are discovered within the facility.

(6) Assisting the facility Records Manager with staff training related to their records management responsibilities, at least annually.

(7) Conducting regular internal record reviews to ensure an effective records management program is maintained for their respective service line, program office or

CBOC.

(8) Ensuring departing/terminating employees do not remove any facility records from VHA custody and that they transfer custody of the records to appropriate employee or office prior to being cleared.

(9) Assisting the facility Records Manager with the Vital/Essential Records program, in accordance with the VA-wide program in VA Handbook 6300.2, Management of the Vital Records Program.

(10) Ensuring all inactive record storage locations meet the requirements of 36 CFR 1234, Subpart B, Facility Standards for Records Storage Facilities.

k. All VHA Personnel. All VHA Personnel are responsible for compliance to established VHA records management policies and processes within this directive to include:

(1) Cooperating with the facility Records Manager and Records liaisons in creating, maintaining, protecting, and disposing of federal records in accordance with the facility records management program. Assisting with the transfer of eligible records to NARA approved records storage centers.

(2) 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.

(3) Understanding what constitutes a Federal record and applying VA, VHA, and NARA regulations and guidance to all Federal records.

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

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

(5) Reporting the accidental/unauthorized destruction or catastrophic loss of facility records to their immediate supervisor and their service records liaison in a timely manner as required by 36 CFR 1230.

(6) Ensuring proper authorization is obtained before removing records from the facility.

6. MAINTAINING AND USING RECORDS AND INFORMATION

a. Records Life Cycle. VHA will manage records throughout their life cycle, which includes the following components:

(1) Records Creation/Collection. This is the first stage of the life cycle of records.

An official record is created when an item documents VA functions, operations, policies, decisions, procedures, or essential transactions. Records may be created in the medium and format that meets VHA’s administrative needs. Consideration must be given, however, to the length of time the records will be maintained to ensure that the information, and the technological methods and devices necessary to decipher it, will be available for its expected life.

(2) Records Maintenance and Use. This is the second stage of the life cycle of records. Phases of this stage of the life cycle include filing, retrieving, use, duplication, printing, dissemination, release, and exchange of the records.

(3) Records Disposition. This is the final stage of the life cycle of records. The record is either destroyed as a temporary record or legally transferred to NARA as a permanent record.

b. Use of Information and Records.

(1) The records and information collected and created by VHA personnel in the conduct of official business belong to the Federal government and not to the employee who initiated their collection or creation. Legal authorization to sell, reassign to another government agency, destroy/erase, or otherwise remove records and information from VHA control must be obtained from the Archivist of the United States, NARA, via the VHA Records Officer.

(2) If records or information are collected or created by VHA in any form or medium, they must not be disposed of (destroyed, erased, loaned, or otherwise removed from VHA custody) without authorization from NARA.

(3) If records or information being collected or created involve a computer matching program, the OMB Guidelines for Computer Matching Programs and VA Handbook 6300.7, Procedures for Computer Matching Programs, apply. NOTE: A computer matching program is any computerized comparison of two or more automated systems of records. A matching program covers the actual computerized comparison and any investigative follow-up and ultimate action.

(4) If records or information being collected or created will be received from or provided to other agencies, it may be necessary to establish formal agreements with the agencies involved. Refer to 36 CFR 1228.70 for guidance. The appropriate Records Manager must consult with the facility Privacy Officer to determine the need for a Business Associate Agreement (BAA).

(5) Privacy Threshold Assessment (PTA), Privacy Impact Assessment (PIA), and System of Records Notice (SORN). The facility Records Manager must assist System Owners, Information Security Officers, and Privacy Officers in the completion of the “Retention of Information” Section of PTAs, PIAs, and SORNS, as necessary, to ensure that these documents contain accurate information regarding records retention, confirmation of NARA-approved retention schedules and procedures for the disposition of records containing sensitive personal information. The Records Manager must also monitor the completion of the “Policies and Practices for Retention and Disposal of Records” section of System of Records Notices by assisting Privacy Officers when the Privacy Officer is completing this section as necessary.

(6) Prior to transferring, any scheduled permanent records must meet the standards of and be approved by the Archivist of the United States, NARA. Refer to 36 CFR, chapter XII, subchapter B. If the record is unscheduled the record must first be appraised and or approved for transfer by NARA.

(7) If VHA records or information are to be turned over to, or collected, created, maintained, used, processed, or handled in any way by a contractor, Title 41, United States Code, Public Contracts, and 36 CFR, chapter XII, subchapter B, apply.

(8) The records and information of VHA must be protected, used, disseminated, or released only in accordance with applicable Federal laws and regulations.

(9) Duplication, copying, and printing of records, information, and informational products must be done only in accordance with applicable Federal and VA regulations and policies.

(10) The dissemination or release of any records and information within and outside VHA must be in accordance with Federal statutes and VHA policy. In some instances, it may be necessary to maintain sensitive records and information in locked or password-protected files or restricted-access areas for reasons of security.

(11) Electronic media information systems may require special design to maintain appropriate security and confidentiality, particularly when sensitive information is transmitted via standard telecommunications networks. VHA officials must be aware of the sensitivity levels of the information for which they are responsible and must also be aware of the security capabilities of the technologies being used.

(12) Information about an individual that is retrieved by means of that individual’s name or personal identifier must be maintained in a system of records in accordance with a published Privacy Act System of Records Notice (SORN) that describes the maintenance of that system. Notices of new proposed routine uses, including proposed computer matching activities, must be published in the Federal Register for public comment prior to implementation. The new use of the information cannot be implemented until at least 30 days after publication of the Notice. Refer to VA Handbooks 6300.4, Procedures for Processing Request for Records Subject to The Privacy Act; 6300.5, Procedures for Establishing and Managing Privacy Act Systems of Records; and 6300.7, Procedures for Computer Matching Programs for guidance.

c. Documenting Official Actions and Activities.

(1) VHA officials are responsible for incorporating into the records of VA all essential information on their major actions. Significant decisions and commitments reached orally or by informal electronic mail should be documented and included in the record.

Minutes should be taken at important meetings, and these, together with a copy of the agenda and all documents considered at or resulting from such meetings, should be made part of the record.

(2) The programs, policies, and procedures of VHA should be adequately documented in appropriate directives. The case file of each such directive and supporting documentation, including those superseded, must be maintained as a part of the official files. At the VHA level these official policy documents are maintained in the Office of Regulatory and Administrative Affairs, or successor office.

(3) Papers of a private or nonofficial character that pertain only to an individual's personal affairs that are kept in the office of a VA official must be clearly designated by him or her as nonofficial and must at all times be filed separately from the official records of the office. In cases where matters requiring the transaction of official business are received in private personal correspondence, the portion of such correspondence that pertains to official business must be extracted and made a part of the official files. In the case of e-mails care must be taken not to mix official VA business activities with personal comments and discussion; otherwise, intermixed personal comments may become part of the official government record.

(4) VA officers and employees are generally prohibited from creating or sending a record using a non-official electronic messaging account unless such officer or employee: (1) copies an official electronic messaging account of the officer or employee in the original creation or transmission of the record, or (2) forwards a complete copy of the record to an official electronic messaging account of the officer or employee not later than 20 days after the original creation or transmission of the record. Provides for disciplinary action against an agency officer or employee for an intentional violation of such prohibition (See Pub. L. 113-187, Presidential and Federal Records Act Amendment of 2014). Additional information on this subject can be found in VA Handbook 6301, Procedures for Handling Electronic Mail Records, and VA Directive 6500, Managing Information Security Risk: VA Information Security Program.

(5) In planning the creation of a new Electronic Information Systems (EIS), the life cycle of the records and information must be considered. The appropriate staff, including the facility Records Manager or Program Office Records Coordinator, must be consulted in the initial planning to ensure the records and information created or generated are properly scheduled.

d. Contingency Records Planning. The following requirements must incorporate Vital/Essential records management planning as it relates to the facility Continuity of Operations Plan (COOP) per VA Handbook 6300.2 Management of the Vital Record Program. NOTE: National Archives and Records Administration (NARA) has been transitioning from the term Vital Records to Essential Records. A records management “Risk Assessment” must be conducted as part of the COOP and the Vital/Essential Records plan. A risk assessment is necessary in order to conduct the agency/facilities mission, function and operations, during or after events such as: hurricanes, earthquakes, forest fire, flooding or a technological event. The Records Manager must:

(1) Consult with the facility Emergency Preparedness Coordinator to review the facility COOP and ensure that records management requirements, to include the Vital/Essential Records Plan, are included in the facility COOP. Decide which actions will be taken by the facility Records Manager or Program Office Coordinator, in conjunction and in support of the Emergency Preparedness Coordinator. (See paragraph 5.h.(9).)

(a) Determine records necessary to deliver the minimum level of service and functionality (i.e. the first hour, day, week).

(b) Determine pre-positioned location(s) for Vital/Essential records (paper and electronic) taking into consideration the risks associated with the pre-positioned location(s) for natural disasters.

(2) Test the Plan: A records management risk assessment is a process improvement exercise that should be tested on a regular basis but at least annually.

(3) Test the Contingency Records Plan to determine whether Vital/Essential records were available and were sufficient to operate the facility under other than normal operating conditions.

(4) Consult with the Emergency Management Preparedness Coordinator to determine vulnerabilities and risks. Risk assessment is a continuous process improvement exercise that must be tested on a regular basis, but at least annually.

(5) For additional information refer to VA Handbook 6300.2, Management of the Vital Records Program, and VA Handbook 0320, Comprehensive Emergency Management Program. For additional responsibilities of the Records Manager, see paragraph 5.h.

7. FILE MANAGEMENT

The records and information collected and created by VHA must be maintained in a manner that allows their ready retrieval whenever necessary throughout the approved life cycle of the information. The records maintenance process must include the application of authorized disposal requirements, including the identification and retention of records of permanent value. This is accomplished through the establishment and implementation of files management standards and procedures.

VHA will make reasonable efforts to maintain records in formats or media that are reproducible for purposes of Freedom of Information Act (FOIA) actions. (See VHA Directive 1605.01, Privacy and Release of Information, dated August 31, 2016.) File management includes the following:

a. Textual (Paper) Files.

(1) Standards and procedures must be established for classifying, indexing, labeling, and filing the records and information to ensure their ready access and retrievability for conducting VHA business. All textual records must be filed in appropriately labeled file folders or binders.

(a) Special media, such as photographs, maps, and oversized materials, must be stored in appropriate containers.

(b) File cabinets must be labeled to correlate with the Records Inventory and File Plan.

(c) All records must be maintained either chronologically or alphabetically, and by Fiscal Year (FY) or Calendar Year (CY), depending on the record series.

(d) Personal papers and non-record materials must be maintained separately from official VHA records.

(2) Standardize procedures for retrieval, charge-out, and refiling records and information.

(3) The facility Records Manager or Program Office Records Coordinator is required to monitor active records in all non-monitored unmanned on-site storage spaces as needed to ensure the protection of the records and be able to provide documentation of monitoring for compliance. A Temporary Records Storage Basic Checklist can be utilized for documentation of monitoring of on-site records storage.

b. Electronic Files.

(1) Electronic files are to be organized so that complete records are maintained and can be retrieved efficiently. Files must be organized by Service-line, Department and/or work center in an organized method. The use of a consistent naming convention enhances the ability to locate records.

(2) All electronic records need to be organized on the Share Drive or other VA approved electronic information system by service-line, department and work center.

This is considered to be the process of mapping the locally approved Share Drive, SharePoint, etc. folders. It is recommended that this be done as a facility committee that includes the Records Manager, Information Security Office (ISO) and Office of Information & Technology (OI&T) staff.

(3) The records can then be divided by: Permanent, Temporary, convenience copy, and non-record material. NOTE: The records schedules for both permanent and temporary records are found in RCS 10-1 and the NARA GRS. Convenience copies are items such as VA and VHA often-used directives, handbooks or copies of other organizations’ original records being used as a reference. Non-records include copies of journal studies or other online material that the employee may need to study or reference at a later date. Convenience copies and non-records folders must be clearly marked and maintained separate from official VHA records.

(4) Permanent and temporary electronic records must be organized by subject based on RCS 10-1 and NARA GRS. No more than one record type is to be placed in a file folder (i.e. contract files must not be mixed in the same folder as travel claims).

(5) Once the folders have been segregated by subject based on RCS 10-1 and GRS then a file naming convention must be determined.