Licensed Organization:____________________________________
License Number: _____________________
Itemize Data Returned to IES - List each CD-Rom title: (Do not list non-restricted-use CD-Roms, e.g.: NAEP DataToolkit, ECB for Windows CD, or any public-use data CD-Roms.)
Date CD-Roms placed in mail (mm/dd/yyyy): _____________________
Data Destruction: (Check box for all items purged or destroyed; list method of destruction for each. CD-Rom back-up copies must be broken or shredded; computer files must be purged & overwritten; hard copy output must be shredded.)
Computer model(s) used: _______________________________ Number of computer(s) used: ______ Type of computer media used for data back-up copies:________________________
Data on hard drive(s) – purged & overwritten Destruction method: ______________________
All back-up copies of the data – destroyed Destruction method: ______________________
Hardcopy printouts of data – destroyed Destruction method: ______________________
Certification Statement
As the Principal Project Officer (PPO) of an Institute of Education Sciences (IES) restricted-use data License, I certify by my signature below that I have: 1) returned all CD-Roms of the restricted-use data that were licensed to myself through the above named institution, 2) destroyed all derived, backup, and/or other computer files containing these same restricted-use data, 3) destroyed all hard copy output of these data, and 4) will forward and have all users on this License forward any remaining draft documents that used these data to IES for a disclosure review prior to disseminating these documents to non-Licensed persons.