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Statistical Standards Program

Appendix M: License Close-out Certification Form

License Close-out Certification Form

Institute of Education Sciences (IES)

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.)

1. ___________________
2. ___________________
3. ___________________
4. ___________________
5. ___________________
6. ___________________
7. ___________________
  8. ___________________
  9. ___________________
  10. __________________
  11. __________________
  12. __________________
  13. __________________
  14. __________________
  15. __________________
  16. __________________
  17. __________________
  18. __________________
  19. __________________
  20. __________________
  21. __________________
(Continue list on a second form if necessary)

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.

Principal Project Officer (PPO):
Name (print)

Data Destruction Witnessed/Confirmed By:
Name (print)
Email Address

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