Chapter 15 - Records Management Program

Title	Section
Introduction	5-15.1
Purpose	5-15.1A
Background	5-15.1B
Scope	5-15.1C
Policy	5-15.1D
Authorities	5-15.1E
Privacy	5-15.1F
Freedom of Information Act	5-15.1G
Definitions	5-15.1H
Responsibilities	5-15.2
Director, IHS	5-15.2A
Director, Office of Management Services	5-15.2B
Director, Division of Acquisition Policy	5-15.2C
Director, Division of Regulatory Affairs	5-15.2D
Director, Office of Information Technology	5-15.2E
Director, Headquarters Offices	5-15.2F
Lead Consultant, Health Information Management	5-15.2G
Managers	5-15.2H
Records Management Officer	5-15.2I
Records Liaison	5-15.2J
Employees	5-15.2K
Area Director	5-15.2L
Area Records Liaison Officer	5-15.2M
Area Records Liaison	5-15.2N
Procedures	5-15.3
Records Management Inventory	5-15.3A
File Plan Development	5-15.3B
Records Classification	5-15.3C
File Codes	5-15.3D
Capture of Records in Recordkeeping Systems	5-15.3E
Records Disposition Schedules	5-15.4
Disposition of Records	5-15.5
Records Storage	5-15.5A
Transfer of Permanent Records to the National Archives	5-15.5B
Unscheduled Records	5-15.5C
Destruction of Records	5-15.5D
Treatment of Records during a Reorganization, Relocation, or Assumption by Tribes	5-15.6
Relocation	5-15.6A
Reorganization	5-15.6B
Assumption by Tribes	5-15.6C
Procurement of Contractor Destruction Services	5-15.7
Vital Records	5-15.8
Litigation Holds	5-15.9
Training and Guidance	5-15.10
Records Management Assessment Process	5-15.11
Employee (Federal or Contractor) Departure	5-15.12

Exhibit	Description
Manual Exhibit 5-15-A	"IHS-970, Records Management Inventory Worksheet"
Manual Exhibit 5-15-B	"IHS-971, Electronic Records Inventory Worksheet"
Manual Exhibit 5-15-C	"Request for Change in IHS Records Schedule"
Manual Exhibit 5-15-D	"IHS-969, Certificate of Records Destruction"
Manual Exhibit 5-15-E	"Records Management Self-Assessment Tool"

5-15.1  INTRODUCTION

1. Purpose.  The purpose of this revised and updated chapter is to publish the policy, practices, procedures, and staff responsibilities pertinent to creating, maintaining, and providing access to Indian Health Service (IHS) textual and electronic records.
2. Background.  All Federal agencies are required to establish a records management program.  All Federal agencies are required to create and preserve records containing adequate and proper documentation of the organization, functions, policies, decisions, procedures, and essential transactions.  These records are the property of the Federal government and must be managed according to applicable laws and regulations.
3. Scope.  This chapter applies to all employees and individuals, who are working under contract or an interagency agreement, or a cooperative agreement, or a memorandum of understanding (MOU), or any other agreement instrument with the IHS.
4. Policy.It is the policy of the IHS to create, receive, and maintain official records that provide adequate and proper documentation of the organization, functions, policies, decisions, procedures, and essential transactions of the Agency.
5. Authorities
   1. Federal Records Act of 1950, as amended, 44 United States Code (U.S.C.) Chapter 21 (National Archives and Records Administration - (NARA)
      https://www.archives.gov/about/laws/nara.html Exit Disclaimer: You Are Leaving www.ihs.gov 
   2. Federal Records Act of 1950, as amended, 44 U.S.C., Chapter 29 (Records Management by the Archivist of the United States and by the Administrator of General Services)
      https://www.archives.gov/about/laws/records-management.html Exit Disclaimer: You Are Leaving www.ihs.gov 
   3. Federal Records Act of 1950, as amended, 44 U.S.C., Chapter 31 (Records Management by Federal Agencies)
      https://www.archives.gov/about/laws/fed-agencies.html Exit Disclaimer: You Are Leaving www.ihs.gov 
   4. Federal Records Act of 1950, as amended, 44 U.S.C., Chapter 33 (Disposal of Records)
      https://www.archives.gov/about/laws/disposal-of-records.html Exit Disclaimer: You Are Leaving www.ihs.gov 
   5. 15 U.S.C. 7001 (Electronic Signatures in Global and National Commerce (E-Sign Act))
      https://www.gpo.gov/fdsys/pkg/PLAW-106publ229/pdf/PLAW-106publ229.pdf Exit Disclaimer: You Are Leaving www.ihs.gov 
   6. 18 U.S.C. 2071 (b) (Fines and Penalties)
      http://www.archives.gov/about/laws/concealment-removal-mutilation.html
   7. 44 U.S.C. Chapter 35 (Paperwork Reduction Act)
      http://www.gpo.gov/fdsys/pkg/PLAW-104publ13/html/PLAW-104publ13.htm
   8. 36 Code of Federal Regulations (CFR) Parts 1220 to 1239 (Records Management)
      http://www.ecfr.gov/cgi-bin/text-idx?SID=df391b1256d35faec7217ed4af556ef3&c=ecfr&tpl=/ecfrbrowse/Title36/36cfrv3_02.tpl Exit Disclaimer: You Are Leaving www.ihs.gov 
   9. Office of Management and Budget (OMB) Circular A-123 (Management's Responsibility for Internal Control)
      http://www.whitehouse.gov/omb/circulars/a123/a123_rev.html Exit Disclaimer: You Are Leaving www.ihs.gov 
   10. OMB Circular A-130 (Management of Federal Information Resources)
       http://www.whitehouse.gov/omb/circulars_a130_a130trans4 Exit Disclaimer: You Are Leaving www.ihs.gov 
   11. Federal Emergency Management Agency (FEMA)
       http://www.fema.gov/media-library/assets/documents/86284 Exit Disclaimer: You Are Leaving www.ihs.gov 
   12. Presidential Memorandum, Managing Government Records, November 28, 2011
       http://www.whitehouse.gov/the-press-office/2011/11/28/presidential-memorandum-managing-government-records Exit Disclaimer: You Are Leaving www.ihs.gov 
   13. Memorandum for the Heads of Executive Departments and Agencies and Independent Agencies, from OMB and NARA, Managing Government Records Directive, August 24 2012
       www.whitehouse.gov/sites/default/files/omb/memoranda/2012/m-12-18.pdf Exit Disclaimer: You Are Leaving www.ihs.gov 
   14. Department of Health and Human Services (HHS) OCIO-2007-0004.001 "HHS Policy for Records Management," November 25, 2015
       http://www.hhs.gov/ocio/policy/2015-0004.002.html Exit Disclaimer: You Are Leaving www.ihs.gov 
6. Privacy.  The IHS shall safeguard personal information contained in any recordkeeping system.  Each office maintaining records and information about individuals shall establish appropriate administrative, technical, and physical safeguards to protect personal information from misuse, alteration, or unauthorized disclosure.
7. Freedom of Information Act.  The Freedom of Information Act (FOIA), 5 U.S.C. § 552, is a Federal access law which allows for full or partial disclosure of records controlled by Federal government agencies.  The FOIA generally provides that any person has the right, enforceable in court, to access Federal agency records, unless the records they seek are exempt.  Records not exempt from disclosure under the Act shall, upon request, be made readily accessible to the public.
8. Definitions.  Records management terminology may be located on the IHS website at: https://www.ihs.gov/DRA/recordsmanagement/

5-15.2  RESPONSIBILITIES

1. Director, IHS.  The Director, IHS, is administratively responsible for ensuring that the Agency creates and preserves records that adequately and properly document the organization, functions, policies, decisions, procedures, and essential transactions.
2. Director, Office of Management Services.  The Director, Office of Management Services (OMS), is responsible for administering a records management program that adheres to applicable Federal laws and regulations and operates in an economical and efficient manner.
3. Director, Division of Acquisition Policy.  The Director, Division of Acquisition Policy (DAP) shall ensure that:
   1. All contracts, regardless of type, clearly identify IHS ownership.
   2. All contractor records that are created, received, and used by contractors while performing work for the IHS are delivered to the Director, Division of Regulatory Affairs (DRA).
4. Director, Division of Regulatory Affairs.  The Director, DRA, is responsible for leadership, planning, overall policy, guidance, and general oversight of the IHS records management program and its incorporation into the broader information resources management framework.  The Director will ensure that all IHS employees and contractors will:
   1. Create, receive, and maintain official records providing adequate and proper documentation and evidence of IHS' activities.  Agency staff using the information must manage and preserve the materials in accordance with applicable statutory and regulatory requirements.
   2. Manage records, in any format (e.g., paper, e-mail, electronic documents, images, maps, video, blogs, and other social media tools that generate communications), in an orderly manner and in accordance with applicable statues, regulations, and HHS policy and guidance.
   3. Migrate electronic records in legacy systems to an IHS approved electronic records management system, when feasible.
   4. Print and file records in a paper recordkeeping system when an approved electronic records management system or application is not available.
   5. Maintain records according to the Agency-wide file structure allowing for timely access and retrieval.
   6. Ensure that Agency records are disposed of in accordance with mandatory instructions as specified in the approved records schedules.
5. Director, Office of Information Technology.  The Director, Office of Information Technology (OIT), also designated as the Chief Information Officer (CIO), shall make certain that:
   1. Information Systems Security Officers (ISSO) and other designated information technology staff work with the Records Management Officer (RMO) to establish and update records schedules for electronic information systems (EIS).
   2. Recordkeeping functionalities are incorporated into existing information systems and planned technology investments to reflect business processes.
   3. Electronic information systems are maintained in accordance with approved records schedules and NARA requirements.
   4. Internet and intranet postings containing official records are maintained in accordance with mandatory instructions found in an approved records schedule.
6. Director, Headquarters Offices.  The Director of each Headquarters Office shall make certain records are created in accordance with recordkeeping requirements.  All office components will incorporate records management policies, practices and procedures into their programs.
7. Lead Consultant, Health Information Management.  The Director, OIT, oversees the Lead Health Information Management (HIM) Consultant, who shall work jointly with the RMO and other Resource and Patient Management System (RPMS) module owners to ensure that retention and disposition instructions for administrative and clinical data in RPMS is described in a records schedule.
8. Managers.  Managers shall ensure adequate and proper documentation of Agency activities to comply with Federal laws, regulations, and other guidance which serve as the basis for the creation of records.  In addition, they must designate staff to oversee records management activities (e.g., records inventory, file plan development, transfer of records, records destruction, etc.,) and ensure that the employees under their supervision attend or complete mandatory Departmental or IHS records management exercises or workshops.
9. Records Management Officer.  The role of the RMO is an assigned responsibility to a person with appropriate authority to coordinate and oversee the comprehensive records management program.  The RMO must review all proposals to convert Agency paper records to electronic formats to determine whether the alternative is economical and programmatically feasible.
10. Records Liaison.  The Records Liaison is a designated appointment in writing via memorandum.  The Records Liaison serves as the primary contact for questions about records management and other activities associated with recordkeeping within their office.
11. Employees.  All IHS employees are responsible for:
    1. Creating and managing the records necessary to document the Agency's official activities and actions, including those records generated by IHS contractors and grantees, in accordance with IHS recordkeeping requirements.
    2. Destroying records only in accordance with an approved RDS and never removing records from the IHS without authorization.
    3. Maintaining records in safe and NARA-approved storage areas that promote efficient retrieval and keeping personal papers and non-record materials separately from official IHS records.
12. Area Directors.  Each Area Director must implement, operate, and sustain a records management program.  The Area Director shall ensure that records created or received adequately document IHS actions in accordance with recordkeeping requirements.
13. Area Records Liaison Officer.  The Area Records Liaison Officer (RLO) must be appointed by the Area Director via memorandum and is accountable to the Area Director or another official designated to oversee the program.  The Area RLO provides Area-wide support and technical assistance to Area Office employees, health care facility employees and others on records management issues.
14. Area Records Liaison. Area Records Liaisons are appointed by the Area Director, via memorandum to coordinate records management activities and work closely with the RLO to implement records management policy, practices, and procedures.

5-15.3  PROCEDURES

1. Records Management Inventory.  All records held by an IHS Office shall inventory their records, regardless of format, on an annual basis.  The inventory data shall be captured using the "IHS-970, Records Management Inventory Worksheet" (Manual Exhibit 5-15-A) and the "IHS-971, Electronic Records Inventory Worksheet" (Manual Exhibit 5-15-B).
2. File Plan Development.  Records Liaisons shall coordinate the preparation and collection of file plans beginning November 1 of each year.  All file plans shall be completed by January 20.
3. Records Classification.  Records classification is the act of analyzing and determining the subject content of a document usually immediately following its creation or receipt.
4. File Codes.  The IHS RMO shall ensure that all offices use consistent file codes to properly mark and identify record materials.
5. Capture of Records in Recordkeeping Systems.  All IHS records, regardless of format, shall be identified, classified, filed, preserved, and stored in approved recordkeeping systems.  The records must be readily available for business or disclosure purposes during their entire retention period.

5-15.4  RECORDS DISPOSITION SCHEDULE

A records disposition schedule (RDS) is a document that provides descriptive information about an Agency's records along with mandatory retention and disposal instructions.  Whenever a records series cannot be identified, the office accumulating the records must request the establishment of a records series using the "Request for Change in IHS Records Schedule."  (See Manual Exhibit 5-15-C) Until the scheduling process is complete, the records must be retained permanently pending approval from NARA.  The IHS RDS is found at:

https://www.ihs.gov/dra/recordsmanagement/dispositionschedule/

5-15.5  DISPOSITION OF RECORDS

The IHS actions with regard to active, inactive, and permanent records created by employees shall include retiring records to a Federal Records Center (FRC), transferring permanent records to NARA, donating temporary records to an individual or organization after obtaining NARA clearance or the physical destruction of records.  Records subject to any current pending audit, litigation, or other legal demand must be preserved and cannot be destroyed.

1. Records Storage.  Individual Offices may store records on-site in office working conditions or send them periodically off-site to an FRC where they are held until destruction or transfer to the National Archives.  The originating office may borrow its records using the Archives and Records Centers Information System (ARCIS).  Permanent withdrawal of Agency records from an FRC is not permitted.  No IHS component is authorized to rent, lease, or purchase warehouse space for the storage of records unless the facility meets approved standards and is sanctioned by the RMO.
2. Transfer of Permanent Records to the National Archives.  It is the policy of the IHS to send permanent records in their original form to the National Archives.  When permanent records are accessioned into the National Archives, the NARA assumes legal and physical custody of the records.
3. Unscheduled Records.  Categories of records not listed in an approved RDS and do not have an assigned retention period cannot be destroyed.  These materials should be brought to the immediate attention of the RMO who will assist with records assessment.
4. Destruction of Records.  The RMO will review disposition notices, i.e., for records stored in an FRC.  The office responsible for the records will be contacted to verify whether there is a business need to keep the records or recommend the records be destroyed.  All IHS staff are required to complete and certify the "IHS-969, Certificate of Records Destruction" (Manual Exhibit 5-15-D) prior to the destruction of records which are stored on-site in IHS offices.

5-15.6  TREATMENT OF RECORDS DURING RELOCATION, REORGANIZATION, OR ASSUMPTION BY TRIBES

Consideration must be given to the treatment of records during events such as a relocation, reorganization, or assumption of programs, functions, services, and activities (PFSAs) by Tribes.  Ultimately, the records should be handled in a manner to further program continuity.

1. Relocation.  Prior to a move, employees must conduct a records inventory to determine the type of records, how many there are, where they are, and in what format the records are maintained.  With this information, staff can begin to assess the value and treatment of the records.  Under no circumstances will employees leave behind documentary materials in offices.
2. Reorganization.  Following a change in the organizational structure, employees must transfer, if applicable, current records supporting a former functional area to the new office.  Records not required by the new office may be eligible for transfer to an FRC.  All finding aids, e.g., file plans, Standard Form-135, and inventory lists must be forwarded to the new office.
3. Assumption by Tribes.  When a Tribe assumes the PFSA once operated by the IHS, the records supporting the PFSA must also be transferred.  The IHS must ensure that a formal agreement between the Agency and the inheriting entity is in place and outlines any continuing obligations to maintain, manage, and store records.  The transfer constitutes a change in custody of the records or the records moving from the possession and responsibility of the IHS to another organization.  Finding aids, e.g., file plans, SF-35's, and inventory lists, must be forwarded to the new organization.  Records not assumed by the Tribe are considered inactive on the date of the assumption and should be transferred to an FRC.

5-15.7  PROCUREMENT OF CONTRACTOR DESTRUCTION SERVICES

To ensure Agency compliance with recordkeeping requirements, all requests to procure records destruction services, regardless of the procurement method, shall be reviewed by the RMO and the Area RLO.

5-15.8  VITAL RECORDS

Vital records are those records that are essential to the daily business of the IHS without which the Agency and/or its individual components could not effectively operate.  The Records Management Program (RMP) will work with offices to identify records needed during and after an emergency or disaster.

5-15.9  LITIGATION HOLDS

The IHS shall preserve records which may be needed for reasonably anticipated or actual government investigation, audit, or litigation.  Individuals in receipt of a litigation hold have a duty to preserve the information, regardless of format, and are required to report to the RMO all records series believed to be relevant to the issue.  The hold temporarily sets aside the retention period stated in an RDS and stops destruction for the affected records until the hold is released.  Disposition actions are also halted for records stored in an FRC by placing a freeze on the pertinent records.

5-15.10  TRAINING AND GUIDANCE

All employees and contractors are required to take annual records management training.  Records management training serves as a reminder of the responsibility to maintain and protect IHS records.  Records management training may be conducted online or in person.  Courses may include, but not be limited to basic records management, file plan development, electronic records management, and vital records guidance.  Supervisors and Contracting Officer's Representatives (COR) are responsible for briefing new employees and contractors regarding the types of records they create and maintain.

5-15.11  RECORDS MANAGEMENT ASSESSMENT PROCESS

The RMP will conduct periodic assessments to monitor the effectiveness, adherence, and performance of the program.  Consistent assessments provide opportunities for refining and improving the program through the establishment of best practices and identification of new cost efficiencies.  (See Manual Exhibit 5-15-E, "Records Management Self-Assessment Tool")

5-15.12  EMPLOYEE (FEDERAL OR CONTRACTOR) DEPARTURE

No political appointee, senior official, employee, or contractor of the IHS shall remove or destroy Federal records upon departure nor may they be destroyed without a records disposition schedule.  This includes records in shared spaces (i.e., electronic records) about which the employee has sole knowledge.  All records under the control of that employee should be reviewed with their manager who will ensure that the records are passed on to the employee's successor or other designee.  Employees must certify that no Federal records are being taken from the Agency.  (IHS Circular Exhibit 2011-02-A, "Indian Health Service Clearance Checklist")