MDH Certificate of Records Disposal Request Form

MDH Certificate of Records Disposal Request Form

Many MDH Records Retention Schedules have been updated to include digitization language. Please click here to locate your schedule(s).

Records materials must be disposed of in accordance with an Agency’s Records Inventory and Retention Schedule (DGS Form 550-1 or records retention schedule). Please complete and submit the following form. The MDH Records Management Office will review and reply to your inquiry within 14 business days. For questions or concerns, please send an email to mdh.recordsoffice@maryland.gov.

Secretariat*

Select

Administration (Ex: PHPA)*

Location (Physical Office Address)*

First Name*

First Name of Person Submitting Form

Last Name*

Last Name of Person Submitting Form

Title*

Phone*

Requestor Email*

Use Only State or County Work E-mail

Records Coordinator E-Mail*

1 Description of Records*

Enter the Description for line 1.

1 Format*

Examples: Paper, Film, Disk, Etc... Enter the Format for line 1.

1 Records Scanned*

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

1 Schedule #*

Enter the schedule # for line 1.

1 Item #*

Enter the Item # for line 1.

1 Inclusive Dates of Records*

Enter the Inclusive Dates of Records for line 1.

1 Volume (Amount of Boxes)*

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 1.

2 Description of Records

Enter the Description for line 2.

2 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 2.

2 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

2 Schedule #

Enter the schedule # for line 2.

2 Item #

Enter the Item # for line 2.

2 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 2.

2 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 2.

3 Description of Records

Enter the Description for line 3.

3 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 3.

3 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

3 Schedule #

Enter the schedule # for line 3.

3 Item #

Enter the Item # for line 3.

3 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 3.

3 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 3.

4 Description of Records

Enter the Description for line 4.

4 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 4.

4 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

4 Schedule #

Enter the schedule # for line 4.

4 Item #

Enter the Item # for line 4.

4 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 4.

4 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 4.

5 Description of Records

Enter the Description for line 5.

5 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 5.

5 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

5 Schedule #

Enter the schedule # for line 5.

5 Item #

Enter the Item # for line 5.

5 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 5.

5 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 5.

6 Description of Records

Enter the Description for line 6.

6 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 6.

6 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

6 Schedule #

Enter the schedule # for line 6.

6 Item #

Enter the Item # for line 6.

6 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 6.

6 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 6.

7 Description of Records

Enter the Description for line 7.

7 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 7.

7 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

7 Schedule #

Enter the schedule # for line 7.

7 Item #

Enter the Item # for line 7.

7 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 7.

7 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 7.

8 Description of Records

Enter the Description for line 8.

8 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 8.

8 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

8 Schedule #

Enter the schedule # for line 8.

8 Item #

Enter the Item # for line 8.

8 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 8.

8 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 8.

9 Description of Records

Enter the Description for line 9.

9 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 9.

9 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

9 Schedule #

Enter the schedule # for line 9.

9 Item #

Enter the Item # for line 9.

9 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 9.

9 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 9.

10 Description of Records

Enter the Description for line 10.

10 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 10.

10 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

10 Schedule #

Enter the schedule # for line 10.

10 Item #

Enter the Item # for line 10.

10 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 10.

10 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 10.

11 Description of Records

Enter the Description for line 11.

11 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 11.

11 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

11 Schedule #

Enter the schedule # for line 11.

11 Item #

Enter the Item # for line 11.

11 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 11.

11 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 11.

12 Description of Records

Enter the Description for line 12.

12 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 12.

12 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

12 Schedule #

Enter the schedule # for line 12.

12 Item #

Enter the Item # for line 12.

12 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 12.

12 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 12.

13 Description of Records

Enter the Description for line 13.

13 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 13.

13 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

13 Schedule #

Enter the schedule # for line 13.

13 Item #

Enter the Item # for line 13.

13 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 13.

13 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 13.

14 Description of Records

Enter the Description for line 14.

14 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 14.

14 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

14 Schedule #

Enter the schedule # for line 14.

14 Item #

Enter the Item # for line 14.

14 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 14.

14 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 14.

15 Description of Records

Enter the Description for line 15.

15 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 15.

15 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

15 Schedule #

Enter the schedule # for line 15.

15 Item #

Enter the Item # for line 15.

15 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 15.

15 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 15.

16 Description of Records

Enter the Description for line 16.

16 Format

Examples: Paper, Film, Disk, Etc... Enter the Format for line 16.

16 Records Scanned

If digitizing paper records (as allowed by your records retention schedule), have the records been scanned in accordance with MSA standards?

Select

16 Schedule #

Enter the schedule # for line 16.

16 Item #

Enter the Item # for line 16.

16 Inclusive Dates of Records

Enter the Inclusive Dates of Records for line 16.

16 Volume (Amount of Boxes)

Whole Numbers - Always Round Up (Ex. 1/10th of a Box = 1 Box) Enter the Amount of Boxes for line 16.

Select this checkbox if your MDH Program is located on West Preston Street and you need assistance disposing of 20 or more records boxes included in this request.

Send me a copy of my responses

Privacy Notice|Report Abuse