DJJ Form AD-IS1260-1 "Data Storage Media Sanitization/Destruction Form" - Florida

What Is DJJ Form AD-IS1260-1?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 29, 2015;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DJJ Form AD-IS1260-1 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form AD-IS1260-1 "Data Storage Media Sanitization/Destruction Form" - Florida

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AD-IS 1260-1
Revised 7/29/2015
Revised: 09/29/2015
State of Florida
Department of Juvenile Justice
DATA STORAGE MEDIA SANITIZATION/DESTRUCTION FORM
Pursuant to DJJ policy, all forms of data storage media (i.e. Hard Drives, USB Drives, Sim Cards, Memory,
etc.) shall be sanitized in compliance with DJJ security standards.
ONLY ONE DEVICE PER FORM
SECTION 1 - Device Information (Please Print)
Device Type: (i.e. computer, laptop, copiers, fax machine, etc.) _________________________________
Device Make/Model:
Device Serial #:
Property Tag Number (if applicable):
SECTION 2 – Storage Media Information (Please Print)
#1. Storage Media Type: (i.e. hard drive, RAM, flash/thumb/jump drive, memory/SIM card, etc.)
_____________________________________________________________________________________________________________________________________________________
Storage Media Make: ________________________________ Serial#:________________________
#2. Storage Media Type: (i.e. hard drive, RAM, flash/thumb/jump drive, memory/SIM card, etc.)
_____________________________________________________________________________________________________________________________________________________
Storage Media Make: ________________________________ Serial#:________________________
#3. Storage Media Type: (i.e. hard drive, RAM, flash/thumb/jump drive, memory/SIM card, etc.)
___________________________________________________________________________________________________________________________________________________
Storage Media Make: ________________________________ Serial#:________________________
 Reimage & Reissue
 Physical Destruction
 Malware Infection
Reason for Sanitization:
Secure Wipe/Erase Date:
OTHER: ________________________________________________________
____________
Physical Destruction Date: __________
Date Certificate of Destruction Received: _________________
N
N
O
O
T
T
E
E
:
: Some devices contain multiple forms of data storage media. If necessary, attach a separate document listing any
additional data storage media. Include the data storage media type, make/model, and serial numbers. Also list the sanitization
and physical destruction date.
SECTION 3 – MIS Contact’s Information & Signature (Please Print)
MIS Contact’s Name: ____________________________________________
Ph:(______) ____________
Address:_______________________________________________________
Region/Circuit: _________
MIS Contact’s Signature: _________________________________________________ Date:__________
I certify that the storage media has been sanitized in a manner which provides reasonable assurance that the data may
not be easily retrieved or reconstructed.
SECTION 4 – MIS Regional Leader Information & Signature (Please Print & Sign/Date)
MIS Regional Leader’s Name: _____________________________________
Ph: (______)___________
MIS Regional Leader’s Signature: __________________________________ Date: _________________
Signature indicates approval of data sanitization/destruction.
Copy to applicable MIS Regional Leader
DISTRIBUTION INSTRUCTIONS:
Retain original for your records
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After the media has been physically destroyed please attach a copy of the
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to this form and submit it to the DJJ
Information Security Manager via e-mail or interoffice mail.
AD-IS 1260-1
Revised 7/29/2015
Revised: 09/29/2015
State of Florida
Department of Juvenile Justice
DATA STORAGE MEDIA SANITIZATION/DESTRUCTION FORM
Pursuant to DJJ policy, all forms of data storage media (i.e. Hard Drives, USB Drives, Sim Cards, Memory,
etc.) shall be sanitized in compliance with DJJ security standards.
ONLY ONE DEVICE PER FORM
SECTION 1 - Device Information (Please Print)
Device Type: (i.e. computer, laptop, copiers, fax machine, etc.) _________________________________
Device Make/Model:
Device Serial #:
Property Tag Number (if applicable):
SECTION 2 – Storage Media Information (Please Print)
#1. Storage Media Type: (i.e. hard drive, RAM, flash/thumb/jump drive, memory/SIM card, etc.)
_____________________________________________________________________________________________________________________________________________________
Storage Media Make: ________________________________ Serial#:________________________
#2. Storage Media Type: (i.e. hard drive, RAM, flash/thumb/jump drive, memory/SIM card, etc.)
_____________________________________________________________________________________________________________________________________________________
Storage Media Make: ________________________________ Serial#:________________________
#3. Storage Media Type: (i.e. hard drive, RAM, flash/thumb/jump drive, memory/SIM card, etc.)
___________________________________________________________________________________________________________________________________________________
Storage Media Make: ________________________________ Serial#:________________________
 Reimage & Reissue
 Physical Destruction
 Malware Infection
Reason for Sanitization:
Secure Wipe/Erase Date:
OTHER: ________________________________________________________
____________
Physical Destruction Date: __________
Date Certificate of Destruction Received: _________________
N
N
O
O
T
T
E
E
:
: Some devices contain multiple forms of data storage media. If necessary, attach a separate document listing any
additional data storage media. Include the data storage media type, make/model, and serial numbers. Also list the sanitization
and physical destruction date.
SECTION 3 – MIS Contact’s Information & Signature (Please Print)
MIS Contact’s Name: ____________________________________________
Ph:(______) ____________
Address:_______________________________________________________
Region/Circuit: _________
MIS Contact’s Signature: _________________________________________________ Date:__________
I certify that the storage media has been sanitized in a manner which provides reasonable assurance that the data may
not be easily retrieved or reconstructed.
SECTION 4 – MIS Regional Leader Information & Signature (Please Print & Sign/Date)
MIS Regional Leader’s Name: _____________________________________
Ph: (______)___________
MIS Regional Leader’s Signature: __________________________________ Date: _________________
Signature indicates approval of data sanitization/destruction.
Copy to applicable MIS Regional Leader
DISTRIBUTION INSTRUCTIONS:
Retain original for your records
C
e
r
t
i
f
i
c
a
t
e
o
f
D
e
s
t
r
u
c
t
i
o
n
After the media has been physically destroyed please attach a copy of the
C
e
r
t
i
f
i
c
a
t
e
o
f
D
e
s
t
r
u
c
t
i
o
n
to this form and submit it to the DJJ
Information Security Manager via e-mail or interoffice mail.