Attch_4 _IT_Media_Sanitization_Certificate.doc
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- Solicitation number
- HSTS04-13-R-CT3025
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Attachment 4 IT Media Sanitization Certificate
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Text version
Information Assurance and Cyber SecurityDivision TSA Form1412 IT Media Sanitization Certificate
IT Media Sanitization Certificate INSTRUCTIONS: The individual performing IT media sanitization must complete and sign this form. The completed form must be sent electronically to the System Owner (SO). The SO must retain a copy and store it in a secure location available for future audit in accordance with TSA SOP 1429 Sanitization of IT Media.
Section I: IT Point of Contact Information:
| Name: |
| Badge Number: |
| Telephone: |
| Email: |
| TSA Employee? |
| Yes FORMCHECKBOX |
No FORMCHECKBOX
| Completion Date: |
Section II: System and Data Information
| System Name (e.g., TSANet, EUC, ICS, etc.): |
| Security Category or Classification: |
| FORMCHECKBOX |
Unclassified FORMCHECKBOX Classified
If classified, identify level:
FIPS 199 Impact Categorization:
(Required for Unclassified)
FORMCHECKBOX
Low FORMCHECKBOX Moderate FORMCHECKBOX High
Section III: Media Information
Physical Asset No.: Serial No.: Media Type:
M: Model:
Provide a detailed statement describing the media:
Section IV: Method of Sanitization
FORMCHECKBOX
Clear (Overwriting with software or hardware on media so that data cannot be recovered)
FORMCHECKBOX
Purge (Degaussing, Secure Erase)
FORMCHECKBOX
Destroy (Physically alter media so that it is no longer usable; disintegration, incineration, pulverization)
Provide a detailed statement describing how the media was sanitized:
Section V: Certification
I certify that I have: (check all that apply)
FORMCHECKBOX
Performed the sanitization of the media indicated above to meet the requirements of TSA SOP 1429 Sanitization of IT Media and TSA Technical Standard 046 IT Media Sanitization.
FORMCHECKBOX
Performed the sanitization of all areas that could be successfully overwritten on the media indicated above.
FORMCHECKBOX
Removed (or obliterated) the label formerly in use.
By signing below, I hereby attest that the above information is accurate to the best of my knowledge. I have also read and understand TSA Standard Operating Procedure 1429 Sanitization of IT Media.
IT Agent Signature: ____________________________________ Date: _______________________ Verifier’s Signature: ___________________________________ Date: _______________________
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