Atch 4 AD 3001 Documentary Matls Cert.pdf

AD 3001 (Rev. 1/13)

UNITED STATES DEPARTMENT OF AGRICULTURE

DOCUMENTARY MATERIALS REMOVAL/NON-REMOVAL CERTIFICATION

AND NON-DISCLOSURE AGREEMENT

In accordance with Directive 3099-001, Records Management Policy for Departing Employees, Contractors, Volunteer and Political Appointees [insert link to

DR 3099-001]

EMPLOYEE NAME: OFFICE:

PHONE PLANNED DEPARTURE DATE:

These provisions are consistent with and do not supersede, conflict with, or otherwise alter the employee obligations, rights, or liabilities created by existing statute or Executive order relating to (1) classified information, (2) communications to Congress, (3) the reporting to an Inspector General of a violation of any law, rule, or regulation, or mismanagement, a gross waste of funds, an abuse of authority, or a substantial and specific danger to public health or safety, or (4) any other whistleblower protection. The definitions, requirements, obligations, rights, sanctions, and liabilities created by controlling Executive orders and statutory provisions are incorporated into this agreement and are controlling.

1. Documentary Materials that May be Removed: Personal Papers

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

2. Records that May Not be Removed

a. Any material regardless of the media (including social media) that meets the definition of a Federal record.

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

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

4. The checklist (Appendix B) must be completed by all employees. Senior Officials and Political Appointees refer to Appendix C for additional guidance.

5. Employees, contractors, volunteers, and political appointees must complete the certification below. Employees and political appointees must meet with their immediate supervisor. Contractors must meet with the Contracting Officers Technical Representative (COTR). Volunteers must meet with the unit’s Volunteer Coordinator.

Are you removing any nonrecord documents, such as extra copies of agency records, from the Department Of Agriculture?

If yes, go to a. If no, go to b.

a. YES, I certify that appropriate agencies officials (named below) have reviewed the documents I am removing from the Department of Agriculture and/or associated agencies, and do not include any documents relating to any pending or contemplated civil, criminal, or administrative proceeding or other program information, that if released, would impair or prejudice the outcome of the proceeding or Government policy determinations, decisions, or other actions (Examples: classified documents; record copies; documents, even though judged to be nonrecords, that will create a gap in the files;

and indexes and finding aids necessary to use the official files).

I agree to keep confidential all nonpublic materials, and agree to refrain from disclosure of said document contents or existence thereof without prior permission from the appropriate Department of Agriculture Official.

SIGNATURE OF EMPLOYEE OR POLITICAL APPOINTEE DATE

b. NO, I certify that I am not removing any documents from the Department of Agriculture or associated agencies.

SIGNATURE OF EMPLOYEE, CONTRACTOR, VOLUNTEER, OR POLITICAL APPOINTEE DATE

6. Approving Officials

NAME OF IMMEDIATE SUPERVISOR, COTR, OR

VOLUNTEER COORDINATOR (PRINT OR TYPE): OFFICE & PHONE:

SIGNATURE OF IMMEDIATE SUPERVISOR, COTR, OR VOLUNTEER COORDINATOR DATE

NAME OF AGENCY, STAFF, OR UNIT RECORDS OFFICER/MANAGER (PRINT OR TYPE):

SIGNATURE OF RECORDS OFFICER/MANAGER DATE

AD 3001 (Rev. 1/13)

DOCUMENTARY MATERIALS REMOVAL/NON-REMOVAL CERTIFICATION

AND NON-DISCLOSURE AGREEMENT

1. Have you reviewed Directive 3099-001 “Records Management Policy for Departing

Employees, Contractors, Volunteers and Political Appointees?

Yes No NA

2. Have you collected all hard copy records and working papers and returned them to their appropriate locations and/or provided them to your supervisor?

3. Have you placed all electronic records and working papers in an accessible location and provided the location to your supervisor?

4. Have you verified that all passwords and other restrictions have been provided to your supervisor or removed from electronic records and working papers?

5. Have you identified and separated personal files (as defined in DR 3099-001 Records Management Policy for Departing Employees, Contractors, Volunteers and Political Appointees) for removal from these formats.

(1) Hard copy?

(2) Electronc?

6. Have you reviewed the personal files that you wish to remove to ensure that no classified materials, records, and nonrecord materials are included?

7. Do you plan to take any hard or electronic nonrecord information from your agency?

8. Will these files be for personal use?

9. Are these files to be used in another agency? (as defined in DR 3099-001 Records Management Policy for Departing Employees, Contractors, Volunteers and Political Appointees) for removal from these formats?

10. Have you listed the materials that you will be removing from your office for approval by the Records Management Officer?

11. Insert the volume of records you are removing:

Cubic feet _____ CD-ROMS _____ DVDs _____ Flash Drive _____Other

12. Work-related files:

a. Have you identified the types of work-related files (convenience copies) in which you have an interest?

b. Have you established procedures for the routine copying of these materials?

13. Have you ensured that the unclassified materials you seek to remove do not contain security classified information, information covered by the Privacy Act, or information that is otherwise prohibited by law?

a. No classified materials are included.

b. No Privacy Act materials are included.

c. No information otherwise prohibited from release is included.

14. Have you ensured that the material you seek to remove is not legally privileged, subject to a litigation hold, or under other legal restrictions?

15. For the nonrecord materials you plan to remove, have the following individuals approved for removal, as appropriate:

a. Supervisor

b. Legal Counsel

c. Records Management Office

d. Privacy Office

e. FOIA Office