Enter the information below to certify you have destroyed all data received and any personally identifiable information connected with the Data Use Agreement (DUA) in accordance to the expired DUA or when the data is no longer needed for the purposes of the DUA, whichever comes first. NOTE ! Do not submit any Sensitive Personally Identifiable Information (SPII) through this form. View a list of SPII examples. First name * Last name * Phone number * Any phone number format will do, but include your area code like: 920-555-1212 Email address * DPI DUA Document Control Number * Enter the DPI DUA document control number for the data destruction. DUA Title * Enter the DUA title to reference the data destruction. Data Destruction Comment * List the reports, records and/or file names that will be destroyed and describe the details of the data destruction methods used. This includes data on electronic media and hard copy materials used (i.e. paper). Do not enter any Sensitive Personally Identifiable Information (SPII) in this section. Planned Data Destruction Date (per DUA) Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2023202420252026 Enter the planned data destruction date per the DUA. Actual Data Destruction Date Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20222023202420252026 Enter the date the actual data destruction occurred. Leave this field blank Submit this Ticket
