Att_4_--_TSA_Form_1412_Media_Sanitization_Certificate.doc

Media Sanitization Certificate INSTRUCTIONS: The individual performing media sanitization must complete and sign this form and store it in a defined location available for future audit.

Section I. Contact Information

Section II. Hardware/Media Information

Type:

Make:

Model:

Section III. Classification Level: (check one)

FORMCHECKBOX

Unclassified FORMCHECKBOX Sensitive But Unclassified FORMCHECKBOX Classified (Secret or Above)

NOTE: Media containing classified information may only be reused to process classified information at or above the level previously contained/processed on the media.

Section IV. 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 MD 1400.3, Information Security Policy’s Information Security Policy Handbook.

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.

FORMCHECKBOX

Affixed the completed TSA Form 1411, Media Disposition Label to the media that indicates that the media was:

FORMCHECKBOX

Degaussed FORMCHECKBOX Destroyed FORMCHECKBOX Overwritten FORMCHECKBOX Re-imaged

Signature

Date

Witnessing Government Official:

Signature

Date

TSA Form 1412, 4/09 [File: 1400.5.1]