HIPAA_Media_Destruction_Form
HIPAA Media Destruction Verification & Chain of Custody Form
Instructions: Complete for any media/device containing ePHI. Retain for 6 years.
Section 1: Media Details
- Media Type (HDD/SSD/Tape/USB/Optical/Mobile): _______________________________________
- Asset Tag / Serial #: _______________________________________
- Capacity: _______________________________________
- Location (site/room): _______________________________________
- Custodian/Department: _______________________________________
- Data Classification (ePHI/PII/etc.): _______________________________________
Section 3: Sanitization/Destruction Method
- Method (NIST 800-88 Clear/Purge/Destroy): _______________________________________
- Tool/Procedure Used (e.g., crypto erase, degauss, shred): _______________________________________
- Standard/Ref (e.g., NIST SP 800-88 Rev.1): _______________________________________
- Performed By (name/sign/date): _______________________________________
- Witness (name/sign/date): _______________________________________
Section 4: Validation
- Verification Method (hash match/visual inspection/cert #:): _______________________________________
- Result: _______________________________________
- Certificate of Destruction/Work Order #: _______________________________________
Chain of Custody Log
| Date/Time | From | To | Signature | Notes |
|_________________|_______________|_______________|________________|___________________|
| | | | | |
| | | | | |
| | | | | |
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