Form 10042 (12/07) 10042 (12/07) PREDICT Notice for Certificate of Data Disposal

OMB # 1640-0012 / Expires 12/31/2013

PREDICT
NOTICE FOR CERTIFICATE OF DISPOSAL
ID #:
Name of Research Project:
Dear ________________:
The PREDICT Coordinating Center (PCC) is hereby notifying you that your Memorandum of
Agreement (MOA) between _______________________ and the PCC and access to the datasets listed
below expired on __________________________. Under the terms of the MOA, upon such expiration,
you agreed to either destroy the data or archive it, if allowed. You must now provide the PCC with a
Certificate of Disposal certifying that any and all copies of the datasets, whether in whole or in part or
on your system or not, have been destroyed or archived per the terms of the MOA.
DATASET(S) TO WHICH ACCESS HAS EXPIRED:
Provider

Dataset Name

Destroy/Archive

The attached Certificate of Disposal must be completed, signed, and returned to the PCC by
__________________. The Certificate may be emailed to PREDICT-contact@rti.org or faxed to the
PREDICT Coordinating Center at +1 866 835 0255. Questions may be directed by telephone to +1 800
957 6422 or via email to PREDICT-contact@rti.org.

Please fill in the requested contact information below.

DHS Authority to Collect This Information:  The Homeland Security Act of 2002 [Public Law 107‐296, §302(4)] authorizes the Science and Technology Directorate to conduct 
“basic and applied research, development, demonstration, testing, and evaluation activities that are relevant to any or all elements of the Department, through both intramural 
and extramural programs.” In exercising its responsibility under the Homeland Security Act, S&T is authorized to collect information, as appropriate, to support R&D related to 
improving the security of the homeland. Principal Purpose:  DHS collects name, organization and title (if any), email address, home and/or work address, and telephone 
numbers for the purpose of contacting individuals regarding the PREDICT project and/or their involvement with PREDICT. Routine Uses and Sharing:  Some of your information 
will be disclosed to PREDICT team members, such as data hosts, data providers, PREDICT contractors, the Predict Coordinating Center, the advisory board, and review board 
members to help us deliver requested PREDICT services and operate the PREDICT Web site and deliver the services you have requested.  Unless you consent otherwise, this 
information will not be used for any purpose other than those stated above.  However, DHS may release this information for an individual on a case‐by‐case basis as described in 
the DHS/ALL‐002 System of Records Notice (SORN), which can be found at: www.dhs.gov/privacy. Disclosure:  Furnishing this information is entirely voluntary; however, failure 
to furnish at least the minimum information required to register (to include full name and email address,) will prevent you from obtaining authorization to access system.  

PRA Burden Statement: An agency may not conduct or sponsor an information collection and a person is not required to respond to this information 
collection unless it displays a current valid OMB control number and an expiration date. The control number for this collection is 1640‐0012 and this form 
will expire on 12/31/2013. The estimated average time to complete this form is 15 minutes per respondent. If you have any comments regarding the 
burden estimate you can write to Department of Homeland Security, Science and Technology Directorate, Washington, DC 20528.  
DHS Form 10042 (12/07)  

Page 1 of 3 

Last Update: 8‐9‐11‐v8 

OMB # 1640-0012 / Expires 12/31/2013

Please Fill in Contact Information
Name
Title
Organization
Address
City

Postal
Code/Zip

State/Province

Country

Email

Phone

Alternate Phone

Fax

DHS Form 10042 (12/07)  

Page 2 of 3 

Last Updated: 8‐9‐11‐v8 

OMB # 1640-0012 / Expires 12/31/2013

PREDICT
CERTIFICATE OF DISPOSAL
__________________________________________________________________________________

ID # _______________
Project Name:
Researcher:

I hereby certify that ALL of the following listed datasets and any copies thereof, whether
paper or digital or whole or partial, which were approved for use pursuant to a
Memorandum of Agreement (the ID referenced above,) have been destroyed or archived
per the terms of the MOA. This includes all datasets or copies of the datasets held by
persons other than myself who were approved for access under the MOA.
DATASET(S) DESTROYED or ARCHIVED: Please initial to certify that proper action has
been taken for each dataset.

Provider

Dataset Name

Destroy / Archive

Date Performed

Date Certificate of Disposal Signed:
Signature of Researcher

To be completed by PREDICT Coordinating Center:
Date of PCC’s receipt of Certificate of Disposal:

DHS Form 10042 (12/07)  

Page 3 of 3 

Last Updated: 8‐9‐11‐v8