Record Retention Policy

I. PURPOSE 

The purpose of this policy is to ensure the integrity and security of all documents and records created, received or maintained in the course of institutional business, protect the interests of faculty, employees, students and of the College, facilitate appropriate access to such documents and records, preserve the confidentiality of such records, as applicable,, reduce the cost of records maintenance and to inform all faculty, employees and administrators of New York Medical College of the standards, requirements and responsibilities for the management, retention and disposition of all records of the College.

II. SCOPE

This Policy applies to all faculty, employees, administrators, schools, departments, divisions, units, institutes and centers of New York Medical College (hereinafter called the "University").

III. DEFINITIONS

The term "record" under this policy means all documents and records, whether written, electronic or recorded matter regardless of its physical form or characteristics, that are created, produced, received or maintained by faculty, employees or componentof the University during their activities for or on behalf of the University or in the transaction of University business.

Examples include, but are not limited to: academic files, administrative files, student files, financial and accounting records, correspondence, books, papers, letters, memoranda, forms, charts, reports, maps, drawings, plans, photographs, films, spreadsheets, computer records, microfilm, microfiche, electronic files, electronic mail, data processing output in media, video recordings, audio recordings, and micrographics or any digitization magnetic tape or other electronic storage of any of thesethings. This policy does not apply to non-records which include preliminary drafts not circulated for comment, duplicate copies of correspondence, duplicate copies of records used for short-term reference purposes, blank forms, stocks of publications, magazines, publications from professional organizations, newspapers, public telephone directories, electronic mail ("e-mail) created during incidental use and transitory messages such as voice mail, telephone messages, self-sticking notes and other messages which are used primarily for the informal communication of information.

IV. POLICY

It is the policy of the University that all records subject to this policy are the property of the University and neither the personal property nor the property of a specific school, department, division, unit, institute or center, that such records are maintained inaccordance with all applicable laws and regulations, the requirements of accrediting and other external agencies, and the standards and procedure prescribed herein, and that records that are no longer needed or of no value are discarded or disposed of as specified in this policy.

V. PROCEDURES

A. General Principles and Responsibilities

1. 1. 1. All faculty, employees, administrators, schools, departments, divisions, units, institutes and centers of the University are responsible for ensuring that all records are created, used, maintained, preserved, and disposed of in accordance with this policy. Electronic and computer records are to be managed consistent with the requirements for traditional records in compliance with this policy.
         
         
      2. All records that are essential to the continued functioning or operations of the University during and after an emergency shall be retained and protected to ensure the University's continued operations in the event of a natural or man-made disaster.
         
         
      3. Records containing confidential and proprietary information shall be securely maintained, controlled and protected to prevent unauthorized access.
         
         
      4. The unauthorized use, removal or destruction of records of the University is prohibited.
         
         
      5. No record or document may be falsified or inappropriately altered in any manner.
         
         
      6. Information pertaining to the unauthorized use, removal or destruction of the University's records or regarding falsifying or inappropriately altering information in a record or document should be reported to management, either directly or through the Institutional Compliance Helpline at 1-866-284-8728.

B. Maintenance of University Records

1. 1. 1. All records shall be maintained and retained in accordance with Federal and state laws and regulations, the requirements of accrediting and other external agencies, and the Records Retention Schedule herein (Attachment I), and any subsequent amendments to such schedule.
         
         
      2. All records shall be retained in a readable format regardless of changes in technology or equipment obsolescence.Printing out the documents and saving to a file system, maintaining the old equipment and software applications, orconverting the records to new technology, may meet this requirement.
         
         
      3. Electronic mail ("e-mail") communications, messages and documents transmitted bye­ mail are subject to this policy if otherwise in a paper format and due to its contents they relate to duties and responsibilities for or on behalf of the University or in the transaction of University business. Such e-mail communications thereby must be retained consistent with the Record Retention Schedule in Attachment I. Each e-mail user is responsible for sorting out messages subject to this policy and for the retention of such University records in compliance with the Records Retention Schedule in Attachment The originator/sender of the e-mail message (or the recipient of a message if the sender is outside theUniversity) is the person responsible for retaining the message. E-mail messages may be retained in electronic form in the mailbox for a period not to exceed ninety (90) days from its receipt, or be printed and filed along with other documents related to the same topic or project. Users may delete e­ mail messages that they are not required by this policy to retain (such as non-record messages and transitory messages) and messages that are being retained in printed form. For additional information regarding e-mail usage see the New York Medical College Electronic Communications Policy Statement and the New York Medical College Policy and Procedure Manual, Department of Information Services, Policy 107 "E-MAIL USAGE AND E-MAIL SECURITY."
         
         
      4. Each department shall designate an individual to serve as the Records Coordinator for their respective area. Each Records Coordinator shall be responsible for implementing and maintaining the records management program within their area consistent with this policy. Each Records Coordinator shall serve as a resource to answer questions regarding the retention and disposal of University records and provide training and guidance for all staff responsible for the execution of record retention and disposal procedures.
         
         
      5. Each Records Coordinator shall prepare a listing of major records used and maintained by the department and shall compare it to the records listed in the Record Retention Schedule in Attachment I. Any records not covered by the RecordRetention Schedule under this policy shall be identified and submitted by the Records Coordinator in writing together with the recommended retention for the prior approval of the Records Retention Committee as provided below.
         
         
      6. Each department head shall periodically, but not less than annually, review with the designated Records Coordinator currently-used records and forms to determine whether these records and forms are adequate and appropriate for each department's requirements. Written documentation of such review shall be maintained by each department head and shall be submitted to the Record Retention Committee.
         
         
      7. Each department head shall periodically, but not less than annually, review with the designated Records Coordinator the Record Retention Schedule in Attachment I to determine any special circumstances that necessitate changes in the retention periods. Written documentation of such review shall be maintained by each department head and shall be submitted to the Record Retention Committee. Requests for changes in retention periods or deviations from specified retention periods are to be submitted in writing to the Record Retention Committee, and may be implemented only after its approval.
         
         
      8. All proposed changes, additions, or revisions to the Record Retention Schedule in Attachment I shall be submitted inwriting to the Record Retention Committee for its initial review and The Record Retention Committee, in consultation with the University's Vice President and General Counsel, shall research the legal, fiscal, administrative, and historical value of the records to determine the appropriate length of time the records will be maintained. All approved changes will be incorporated into the Records Retention Schedule in Attachment I and distributed to the designated Records Coordinators.

C. Disposal of Records

1. 1. 1. Records that have satisfied their legal, fiscal, administrative, and archival requirements are to be disposed of or destroyed in accordance with the Records Retention Schedule in Attachment I.
         
         
      2. Records that cannot be destroyed include records with a permanent retention and records relating to or containing information regarding current, pending, threatened litigation or governmental investigation involving the In theevent of a governmental audit, investigation, or current, pending or threatened litigation or lawsuit, the University is under a legal obligation to preserve all relevant records pertaining to the issues. Consequently, as soon as the University's Office of General Counsel and Institutional Compliance is made aware of such governmental audit or investigation, or current, pending or threatened litigation or lawsuit, the Office of General Counsel and Institutional Compliance shall issue, in writing, a litigation hold directive, to the designated Records Coordinator and department heads involved, as legal custodians, requiring the preservation of all relevant records and suspending the transfer, disposal or destruction of relevant records as may be required by any records retention schedule. The litigation hold directive of E-mail and computer accounts of separated employees willbe maintained by Information Services. The litigation hold directive shall continue in effect until its written release by the University's Office of General Counsel and Institutional Compliance. No employee who has been notified by University Counsel of a litigation hold directive may alter or dispose of any record, including an electronic record, within the scope of thatlitigation hold directive. Violation of the litigation hold directive may subject the individual to disciplinary action, up to and including dismissal, as well as personal liability for civil and/or criminal sanctions by the courts or law enforcement agencies.
         
         
      3. Records must be destroyed in a manner that ensures the confidentiality of the records and renders the information nolonger readable and recognizable as University records prior to disposal. The approved methods to dispose records include, but are not limited to, recycling, shredding, burning, pulping, pulverizing, and magnetizing. Written documentation of such disposal shall be kept and maintained by the designated Records Coordinator.
         
         
      4. "Deletion" of confidential or privacy-protected information in computer files or other electronic storage media is not Electronic records must be "wiped" clean or the storage media physically destroyed by or under the direction of the University's Department of Information Services. These methods of destruction are specified so that records may not be viewed or used by unauthorized persons after they are disposed.

D. Records Retention Committee

The Records Retention Committee is established to review and approve any proposed revisions, additions and changes to the Record Retention Schedule in Attachment I. The Committee shall consist of the Vice President and General Counsel, AssociateVice President for Human Resources, the Controller, the Internal Auditor, the University Registrar, and other representatives asappropriate. The Vice President and General Counsel shall act as Chair of the Records Retention Committee. The Committee will meet at least annually.

VI. Enforcement

Failure to comply with this policy can result in disciplinary action and penalties applicable by law.

This policy shall be periodically reviewed by the Office of General Counsel and Institutional Compliance.

All questions regarding this policy can be directed to the Office of General Counsel and Institutional Compliance.

Approved by: Karl P. Adler, M.D., President and Chief Executive Officer

Date: 8/14/2007

 

ATTACHMENT I RECORDS RETENTION SCHEDULE

 

TYPE OF RECORDS	RETENTION PERIOD IN YEARS
INSTITUTIONAL
Proceedings and Minutes of the Board of Trustees and Academic, Finance and other Administrative reports	p
Faculty Constitution	p
Bylaws of each School	p
Accreditation records	p
Licensure records (Federal, State, Local)	p
Annual Reports	p
General and routine correspondence	3
All other correspondence, memoranda and other documents	p
Faculty appointment and reappointment records Tenured Faculty Non-Tenured Faculty	p 20
Search Committee records	6 years from search commencement
Reports to Government and Funding Agencies	p
Press Releases	3
ACADEMIC/STUDENT RECORDS
Student Academic and Admission Records (including acceptance letters, transcripts, etc.) (a)  For the School of Medicine and the School of Public Health   (b)  For the Graduate School of Basic Medical Sciences	(a) (1) If admitted, 4 years after graduation or date of last attendance; (2)  If not admitted, 4 years after application year.   (b) (1) If admitted, 4 years after graduation or date of last attendance; (2)  If not admitted, 1 year after applicationyear.
Course Catalog	p
Class Schedules	p
Enrollment Statistics	p
Grade records	p

 

TYPE OF RECORDS	RETENTION PERIOD IN YEARS
Degree summaries or Degree audit records	p
Commencement Lists	p
Financial Aid records	5 years after annual audit has been accepted
Tuition fees and schedules	p
Disciplinary action records	5 years after graduation or date of last attendance
Transcripts-admitted	p
Transcript requests	1
USMLE Score Lists	20
National Resident Match Records	20
Academic Calendar	20
Promotion Committee Notes/Minutes	10
Observed Structured Clinical Exam Scores ("Morchand Test")	p
Student Handbooks	p
Student Groups and Organizations records	p
Institutional and Statistical reports	p
International Student & Scholar reports including Foreign Student Form I-20	5 years after graduation or date of last attendance
Student Housing records	2 years after graduation or date of last attendance
Faculty Handbooks	p
Minutes of Faculty Committee Meetings	p
ACGME Directory "Green Book"	3
GME, Fifth Pathway, CME Program files	p
HUMAN RESOURCES
Employment Records
Employment Service and History records	p
Records relating to the Family Medical Leave Act	3
Personnel files including background checks, in-service & training records, immigration records	7*
Employee Benefit records	7*
Employee Medical files	30*
Benefit plans	10 years after all benefits are paid out under the plan. Records pertaining to individual participants to be kept 10 years after the participant (or the joint and surviving beneficiary if applicable) ceases to years after termination

 

* years after termination

 

TYPE OF RECORDS	RETENTION PERIOD IN YEARS
	participate in the plan
Pension, Tax-Deferred Annuity and ERISA benefit records	1 year after plan termination
EEO-6 & Affirmative Action reports	5
Collective Bargaining Agreements	10 years after expiration of agreement
Discrimination Complaints	5 years after disposition
Grievance records	3 years after resolution of grievance, if no litigation, claim, audit, or other officialaction involved. If official action involved, review with Office of General Counsel
Recruitment and applicant records	3 years after date position is filled
Unemployment Insurance records	7
Workers' Compensation Claim records	10*
Policies & Procedures	p
Employee Manual or Handbook	p
Position Description Records Gob descriptions & classification records)	3 years after superseded
Disability Records	10*
Personnel Service records	7*
Retirees and Death Claim records	7*
Attendance, Annual Leave, Sick Leave and other Leave records	7*
Unemployment Insurance Claims	7*
RESEARCH
Research data	3**
Working papers, draft and final proposals	3**
Research/activity reports	3**
Summary reports	3**
Related documentation and correspondence	3**
Grant Proposal Unfunded records not involving human subjects	2 years after last submission
Grant Funded Research Records	3**
Academic Records for human subjects research reviewed by the IRB	3**

 

* years after termination

** years after final financial report is submitted and account is closed or longer if specified by the terms of the contract or if in litigation or in an audit

 

TYPE OF RECORDS	RETENTION PERIOD IN YEARS
Academic Records for human subject research exempt from IRB review	3**
IRB records	3**
Research and Scientific Misconduct records	If not in litigation, 7 years after final financial report is submitted and account is closed. If in litigation, 7 years after end of litigation.
Patent and Technology Transfer records (a)  original patents, formal invention assignment forms, license agreements, patent legal transactions, and invention disclosure forms (b) all other records	(a)  Permanent   (b)  6 years
IACUC Committee records	3**
FINANCE
Accounting
General Ledger	p***
Bank Deposits	3
Cash Receipt Records	3
Fixed Asset Disposal Forms	5
Fixed Assets	2
Depreciation Schedules, Inventory records	p
Balance Sheet	p
Petty Cash records	3
Accounts Receivable Invoices and Ledgers	5
Journal Entries and Support	p
Financial Statements-Periodic	5
Audited Financial Statements	10
Bank Statements	3
Exempt Organization Income Tax Return	p
Authorizations for Wire Transfers	SUP***
Endowment records	7 years after life of endowment.
Budgets - approved	p
Budget documentation	10
Payroll
Payroll Registers	5
Payroll Timesheets	5

 

*** "P" = Permanent

"SUP"=Dispose when superseded

 

 

TYPE OF RECORDS	RETENTION PERIOD IN YEARS
Postings to GL	10
Consoles	10
TDA Bi-Weekly reports	10
(1199) Monthly reports & payments	7
Garnishments	7
Voided Checks records	10
W-2's and 1099 Forms	p
Governments Reports & Tax Forms	p
Payroll Checks and Ach Files	7
EFT Check Req. Payments	10
DataEase Payroll Drives (1994-2003)	p
Savings Bonds reports	10
Census (Govt' Rpts.)	p
Canceled checks	7
Grants Accounting
Grant and contract restricted funds accounts	7****
Project summaries	7****
Grant authorizations	7****
Contract documents	7****
Project budget change and adjustment forms	7****
Time and Effort reports	7****
Invoices	7****
Receipts	7****
Cashier's receipts	7****
Equipment purchase orders	7****
Subcontracts	7****
Grants and contracts monthly budget summary statements	7****
Final financial reports	7****
Related documentation and correspondence	7****
Accounts Payable
Check Summary Report	7
Vendor Invoices and Supporting Documentation	7
Vendor Master file	7
Check Register	7
EFT Wire Transfer Request	7
Canceled check	7
Bursar
Tuition Journal entries	7

 

••• years after annual or final financial report are submitted and account is closed or longer if specified by the terms of the contract or if in litigation or in an audit.

 

 

TYPE OF RECORDS	RETENTION PERIOD IN YEARS
Tuition cash receipts	7
Refund checks tuition	7
Tuition month end back-up documentation	7
Student loan cash receipts & back up	7
Paid in full loan accounts	7
Yearly student loan aging summary	7
LEGAL
Certificates of Incorporation, Bylaws, Amendments	p
Copyrights	p
Mortgages	p
Patents & Trademarks	p
Real Property records	p
Easements	p
Leases, Contracts and Agreements	7 years after termination of Lease, Contract or Agreement
Litigation and Investigation records	7 years after final disposition of litigation or investigation unless otherwise decided by OGC
Administrative Complaints/Charge records	7 years after final disposition
Arbitration records	7 years after final disposition
Insurance Policies	p
Insurance records	7 years after policy expiration
Insurance Claims	5 years after settlement or disposition
DEVELOPMENT OFFICE
Donations - monetary	7 years after expenditure
Donations - property	7 years after disposal
Donor files	p
Planned gifts	p
Alumni records	p
SECURITY
Identification badge records	7
Locks and keys records	5 years after lock disposal

 

 

 

TYPE OF RECORDS	RETENTION PERIOD IN YEARS
Incident reports	7
Building access and parking records	5 years after termination of building access or parking privilege
Annual Crime Statistics reports	7
INFORMATION TECHNOLOGY
Data or Database Dictionary Documentation	3 years after replacement of updated version
Network Design Files	3 years after replacement of updated version
Network and System Usage Files	4
Support Services Files - Hardware	4
Systems and Applications Development Records	3 years after replacement of updated version
System and Database Backup Files	Until 3 successive backup cycles have been completed
System Security Access Files	3
Source Code	The 3 most recent versions of production source code
FACILITIES
Building and Facilities Data Records
Building Surveys and Audits	10
Reports and studies (e.g. FRM, Parking)	20
Physical description of buildings	10***
Maps, drawings, building plans, blueprints	10***
Construction project reports	10***
Equipment inventories	10
Licenses and permits	10***
Inspection reports	10***
Supplies inventories	10
Facilities Management/Maintenance Records
Buildings	3***
Grounds	3***
Mechanical systems	3***
Preventive maintenance schedules	3***
Work orders	5
Equipment and key inventory management	5
Equipment warranties and guarantees, maintenance	5***

 

*** after disposal

 

TYPE OF RECORDS	RETENTION PERIOD IN YEARS
agreements, repair or service documentation, safety inspections
Key control and lock records	5 years after lock disposal
Utility bills (gas, water and electricity usage)	5
Vehicle records (registration, inspection)	3***
Routine management, maintenance and repair of buildings/facilities/equipment	5***
Construction Project Administration Records
Project descriptions and proposals	10***
Contracts, bid requests and purchase orders	10***
Facilities use records and design proposals	10***
Meeting minutes, work forms and project programs	10***
Check lists, specification books and photographs	10***
All related correspondence	10***
Construction/Renovation Records
Feasibility and needs studies	20
Space planning documents	20
Artist's sketches	20
Architects' proposals	20
Models	20
Plans and proposals	20
PURCHASING
Purchase Orders/Requisitions	3
Other purchasing records	5
ENVIRONMENTAL HEALTH & SAFETY
Licenses and Permits	10 years after expiration
License Violations/Citations	3
Federal, State or other Government Reports	p
Material Safety Data Sheets	30
Inspection records	5
Chemical incident records	30*****
Chemical, biological and other hazardous waste disposal records	30
Emergency response plan and procedures	Until superseded
Chemical inventory records	5
Fire alarm and drill records	5
Medical surveillance records	30*****
Protective wear and device records	5

 

***** years after employee termination

 

TYPE OF RECORDS	RETENTION PERIOD IN YEARS
Training records - employee orientation	30*****
Training records - all others	10*****
Fire extinguisher maintenance and inspections	10
Emergency shower and eyewash stations maintenance and inspections	10
Biological Safety Committee records	p
Safety Committee records	p
Radiation licensing records	p
Radiation material handling and disposal records	p
Radiation monitoring and exposure records	30*****
Radiation Safety Committee Meetings minutes	p
INTERNAL AUDITING
Internal Audit reports	10
Internal Audit work papers and related documents	5