Box 43Records Inventory Data Worksheet PrintFo~m
See Instructions in Publication t76, "Inventory and Planning", before Completing Form
Government Agency ~ -~~ ~ /~ ~ a i a y~
~'t ~~• Department I
___..__ __ .._ __ _
_. _
Record Series Title
Date Span ~~ ~ 1
____ _ ... _ . 1
_ ._ __
Records Series
Description
(describe content
and characteristics
of records) ~ T {~ ~ ` ~ ~~
~J V is~.~'
~~ ~ !~ ~ ~ ~ ~~
`~''
Alphabetical
Numerical ~`.;~~ ~ ~ ~~
Arran Pment
g-
{' Chronological
~' Alphanumeric
~' Other (specify)
Not Scheduled
Ret2nti~n
Permanent Retention Period ~~
__ ._ __ ..__._____. _..
~ ; Historic
Scheduled Schedule ~
_ _....__.. ___0~.~-..-1..._..__......` Schedule
Location .........._.
Format Paper i!" Audia-visual (`-Micro ra hic
g p
{".Electronic
Total. Quantity ~` Cubic Feet: ~"' Items Amoun*:
_ __ __.___ _' T P or Items:
YP-
Annual
Accumulation
~"` Cubic Feet
Amount: ~ _ _ _.
Items
Frequency of Use
~' Daily
r" ~/eekly
i :Monthly
(". Seldom _
('_f~iever _.
Restrictions on Use N/A
Records Are: In Poor
Condition Vital (Essential
~ to Operations)
fficial Copies
Name of Person Completing Record ~(~ Wn I Date ~ ~ ~1 ~~
r~ewror~c5iateF;rchives y J M(2011-01-05j