Records and Information Management Program Procedures

These procedures are intended to supplement the Records and Information Retention Policy. They provide greater procedural insight regarding the scope of the RIM program. Department specific procedures will augment these program-level procedures and will be outlined in individual Records Management Plans.

Definitions
1. Records: Refer to information or data in any format, whether paper or electronic, of a legal or official nature that is created or received by institution personnel or third parties and is necessary to conduct institution business, whether related to operations, research, legal, regulatory, or other similar purposes.
2. Records and Information Management: The systematic and administrative control of records, regardless of media, throughout their life cycle to ensure efficiency and economy in their creation, use, handling, control, maintenance, and disposition.
Roles and Responsibilities
1. Policy Owner/Risk Owner: Chief Information Officer (CIO)
  1. Responsibilities include:
    1. Overseeing the RIM Program
2. Policy Steward/Records Manager: Director of Learning Resources
  1. Responsibilities Include:
    1. Assisting in the design and implementation of the RIM Program.
    2. Educating and training Records Liaisons and others involved with record keeping.
    3. Managing the Institution Archive (which is managed by the Church History Department) and oversight of other physical and electronic records repositories.
    4. Being aware of the CES General Retention Schedule (GRS) and implementing changes to Records Management Plans (RMP) as retention changes and develops over time.
    5. Issuing and updating policies and guidelines given on the records retention portion of the Ensign College Intranet as guidelines are received from the CES Privacy Center (CPC) or other applicable entities.
    6. Completing an annual inventory of electronic records centers and electronic records repositories to confirm records retention is being followed.
    7. Completing an annual inventory of physical records (in partnership with the Church History Department) stored in the Institution Archive or in the departments to confirm records retention is being followed.
3. Compliance Coordinator: Privacy Officer (PO)
  1. Responsibilities include:
    1. Providing guidance and support in the risk mitigation efforts of the RIM program.
4. Legal Approver: Office of General Counsel (OGC)
  1. Responsibilities include:
    1. Approving retention changes in the GRS and providing guidance to the RIM program regarding current law.
    2. Letting departments know of Legal holds on their records so that the appropriate records can be placed on hold.
    3. Letting departments know when Legal holds are no longer applicable so that the records can be put back into the regular disposition processes.
5. Compliance Approver: Chief Compliance Officer
  1. Responsibilities include:
    1. Overseeing and coordinating procedures and policy updates.
    2. Managing and overseeing policy approval process.
    3. Reviewing and overseeing training and awareness components.
6. Records Liaisons: Department Representatives
  1. Responsibilities include:
    1. Obtaining training from the Records Manager.
    2. Becoming familiar with RIM guidelines given on the records retention portion of the Ensign College Intranet.
    3. Implementing the RMP of their department.
    4. Managing their department's records.
      1. Which includes and is not limited to, moving finalized records into their appropriate repositories to be stored for retention purposes, assisting in the secure disposal of records that have met their retention, and moving historical records to the appropriate repository so they can be added to the institution’s history.
    5. Attending required Records Liaisons’ meetings and trainings.
7. Representative of the Records and Information Program: Someone designated by the CIO (or in limited circumstance by the PO) to assist in execution of the Program.
8. Administration:
  1. Responsibilities include:
    1. Identifying who reviews and provides approval of any updates or changes to the policy, GRS, and procedures.
9. Deans and Department Heads:
  1. Responsibilities include:
    1. Identifying a Records Liaison for their department.
    2. Reviewing and updating RMP provided by the Records Liaison.
    3. Reviewing records management policies and guidelines, as needed.
    4. Coordinating department activities that may impact RIM Program, such as recordkeeping training, storage, and disposal.
    5. Assisting Records Manager in identifying any departments or centers within their department that (1) have records and (2) are not on the Records Manager’s list of departments.
    6. Identifying any repositories currently used for their college/department’s records or that are maintained by their college/department for the storage of campus records.
    7. Making available to their Records Liaison any Dean or Department Head records that need to be kept for retention or historical purposes.
    8. Each department should become familiar with and follow their RMP based off the GRS and its corresponding procedures. For any unique records not covered in the plan, the department should contact their Records Manager for assistance and information.
Governance
1. Policy
  1. The Records and Information Retention Policy will be updated by the Records Manager with guidance from the CIO, Privacy Officer, and Chief Compliance Officer. The Records Manager will obtain approval from the President’s Executive Council (PEC) and the OGC for changes made to the policy.
2. CES General Retention Schedule (GRS)
  1. The CES GRS is the key tool for managing records effectively. It includes multiple records categories that identify record types and the time period those records must be retained to comply with legal or regulatory requirements, or for business or historic needs. It provides guidelines for disposition through destruction or transfer to institution archives.
  2. The CES GRS is maintained by the CES Privacy Center (CPC) working in conjunction with the OGC.
3. Procedures
  1. The procedures give guidance for how to create and maintain the RIM Program across the institution.
  2. Updates to the procedures are made by the Records Manager under the guidance of the CPC in order to maintain a degree of standardization across CES, while still achieving the customization required by the institution. Both the CIO and Chief Compliance Officer will approve all updates.
Records Management Plan
1. Records Management Plan (RMP)
  1. The RMP is a holistic look of the departments’ records inventories mapped to the CES GRS.
  2. This plan lists all types of records the institution deals with along with their retention, where they are to be stored, how they are to be disposed of, and any other pertinent procedural information.
  3. The RMP for each department is managed by the Records Manager and the corresponding Records Liaison.
  4. Each department’s RMP combined together makes the institution RMP.
2. Records Inventory
  1. This key component of the RMP lists out each type of record held by a department or service area, as well as location, steward, and other essential information.
  2. This inventory is created by the department or area with assistance from a Records Management Representative from either the institution or the CPC.
  3. The inventory is mapped to the CES GRS in order to create a strategic RMP with actionable procedures and guidance on the appropriate handling of records.
Training
1. Records Liaison Training
  1. It is important that the RIM Program provides training to the Records Liaison for each area detailing their responsibilities and giving helpful guidelines.
  2. The Records Manager or a Representative for the RIM Program meets with Records Liaisons about their duties and responsibilities. This is also an opportunity to discuss how and where to transfer records to their appropriate repositories for retention purposes.
2. Records Management Plan
  1. Each department must have an RMP and should be trained in how to use the records repositories.
  2. The Records Manager or RIM Program Representative meets with each area to determine what kinds of records that area generates and supports.
  3. They also discuss where records are stored and provide guidance/training on how/where to transfer the records for retention purposes.
3. Execution/Manage
  1. The RIM Program should have guidelines available to assist Records Liaisons in completing their responsibilities. Making the process as simple and as easy as possible to aid in adoption at all levels of the institution.
4. Institution Level Training
  1. If needed, there should be either online or in-person training held for the whole institution to bring awareness to the RIM issues faced by the institution and to assist Records Liaisons in bringing awareness to records that must be kept.
Use/Access
1. Data Classification
  1. Records are classified based on CES data classification and data handling standards. The four classification tiers are public, internal, confidential, and restricted (sometimes referred to as highly confidential) based on the sensitivity of the data and who should be granted access. Departments are responsible for appropriately classifying their records in line with institution data classification standards.
    1. Restricted
      1. Records containing the most sensitive information that only very specific employees at the institution may have access to are restricted. Departments may designate records as restricted/highly confidential. If designated as restricted/highly confidential, a record may not be transferred to the Church History Department for archiving and may not be disclosed—except to the responsible member of the President’s Executive Council, under their stewardship, or to institutional Legal Counsel—unless disclosure is required by law.
    2. Confidential
      1. All institution records are classified as confidential unless otherwise designated by the department in which the record originated. This designation also limits access to the records to those who have a legitimate use case for access due to the highly sensitive nature of the record.
    3. Internal
      1. Internal records (records not falling under the above categories) are available to be shared within the institution and with appropriate stakeholders as per data sharing agreements when legitimate purposes are in place.
    4. Access
      1. All records containing privileged, confidential, legally protected, or proprietary information must be securely maintained to prevent unauthorized access (e.g., employment records, health records, student records, financial records, counseling records, legal records).
Retention
1. Retention Periods
  1. Retention of data must follow the retention schedule outlined in the RMP. This includes data found in any institution system, department, or repository.
2. Employee/Department Responsibility
  1. Each institution employee is responsible for retaining records according to the RMP as it relates to his or her area of control. Records may be retained or managed by the department in which the record originated or by a representative of the RIM program. If maintained by the department, proper controls should be in place. Each institution employee should notify their Records Manager if a category of institution records is missing from or not appropriately listed in their Records Inventory or RMP.
3. Audits/Litigation Holds
  1. Notwithstanding minimum retention periods, all records shall be maintained until all required audits are completed and shall be kept beyond the listed retention period if litigation is pending or in progress. The Records Manager and/or personnel responsible for retention of applicable records must be notified of any litigation that would require retention of records beyond normal disposition.
Records/Data Storage
1. Physical Records
  1. There are two ways physical records should be stored at Ensign College. Each way is a viable option, and the approach should be determined by the use case and the resources of the institution.
    1. Archive Maintained by Church History Department (CHD)
      1. The majority of Ensign College's physical records are maintained by the CHD. This agreement ensures that records related to the history and management of the College are preserved, archived, or donated as required by the RMP. This agreement is in place for the physical records of the College, due to a lack of physical storage space on campus for records retention.
      2. A risk assessment of the CHD’s procedures and policies should be reviewed periodically to evaluate process alignment and identify any gaps.
    2. Manage in Place
      1. With permission from administration and OGC, departments may decide to leave records within departments’ local physical storage.
      2. Departments must have spaces that restrict access to their confidential and restricted records and information.
      3. In this model it is imperative that the Records Manager provides training on retention to departments.
2. Electronic Records
  1. Electronic Records Center
    1. Electronic records not already stored in a source system should be placed into approved institution repositories where retention and disposition needs can be met.
3. Source Systems
  1. A source system is a platform where records can be both created and stored (such as Workday). When possible, the system should have retention rules that allow for automated retention and disposition of the records it contains.
  2. System owners are responsible for exploring retention and disposition capabilities and building in any possible automation or planning manual cleanup events, as necessary.
4. Inventories of Records/Data Repositories
  1. Church History Department
    1. An inventory of the physical records managed by the CHD should be conducted a minimum of once a year.
  2. Data Inventories (system-related)
    1. An inventory of what information is being collected by systems should be completed a minimum of once a year.
    2. For Electronic Records Repositories, an inventory of what is stored in them should be conducted once a year.
Transfer of Records
1. Guidelines
  1. The requirements for securely transferring records are dependent upon the use case. These guidelines should be considered when determining how best to complete this process.
    1. Records confidentiality should be maintained.
      1. When transferring physical records, use unmarked or coded boxes and only allow the submitting department access to view the contents of the boxes.
      2. Viewing electronic records should be done from a secure location and only the submitting department should be given access to view the contents of their records.
    2. Records must be transferred securely.
      1. For physical records, specific employees with appropriate role-based access controls should be tasked with the transfer of records. The Records Liaison for the department should always be aware that a transfer is occurring even if they did not initiate the transfer.
      2. Electronic Records should not be transferred over an unsecure or free network (e.g., free Wi-Fi at a coffee shop).
    3. Access to records should be limited.
      1. Only the submitting department should view their records. If another department needs to see their records, you must obtain the submitting department’s permission.
        This permission should be documented.
      2. For electronic records, the departments should have limited access (e.g., viewer/uploader permission). Only the Records Liaison, with training, should have full permission to the electronic records.
    4. Transfers should be documented and legally defensible.
      1. The institution should have in place a process by which transfers are made. This process should include documentation of the transfer including who or which department initiated the transfer, what was transferred, where it was transferred to, and a signature of receipt of the transfer.
      2. If permission is received for a department other than the submitting department to view the records, this must be included in the documentation of the transfer.
Disposition
1. Disposal
  1. Once the specific retention period for any paper or electronic record has been reached, records of the institution should be securely disposed of in an appropriate manner according to the RMP, either by the department or by a representative of the RIM program. Destruction of records is permitted in accordance with the law only after expiration of the retention periods stated on the approved GRS and there are no litigation holds or ongoing audits.
  2. When records are disposed of, the departments or the RIM program should maintain a legally defensible paper trail that contains when the records were destroyed, what their retention period was, and that they were not on legal hold.
2. Archival
  1. Department records may be sent to the CHD where they are managed for the duration of their respective retention periods. Records of historical and continuing value that are not classified as restricted/highly confidential are then available for research according to the institution’s applicable data governance standards and related procedures.
3. Risk Mitigation
  1. All disposition procedures must be well documented, legally defensible, and repeatable. They need to be performed in a secure manner to mitigate potential risk and protect any sensitive or personal data.
Source Systems
1. RIM at the Source System
  1. RIM, including all its phases, should be considered at the source system level. This includes retention of data, access, disposition, and litigation holds. Source systems contain vital records/data to the institution and handling of this data must be done in line with the institution’s RMP.
2. System Owners
  1. System Owners are responsible for overseeing proper protocols are fulfilled.
Vital Records
1. Vital/Critical Records
  1. These are records that are critical to the function of the institution or department. These records are typically found in large, institution-wide systems and are the most critical to mitigating risk.
2. Records Manager Responsibility
  1. Using the RMP, the Records Manager will determine which record types are vital/critical. They will then be reviewed by the Administration or OGC for any additions or subtractions to the list. After review they will be called out in the RMP for the institution.
  2. The Records Manager oversees making sure that all departments are aware of what records are Vital/Critical.
Litigation Holds
1. Legal/Litigation Holds
  1. A systematic or written directive from the institution’s OGC to suspend the application of the RIM Retention policy for the destruction or alteration of information that is considered relevant to pending, threatened, or imminent litigation or government investigation. All personnel should comply with litigation holds received from their OGC.
  2. Once a hold is no longer in place, the OGC will notify all parties involved of the removal of the hold and the suspended records move back to their regular disposition. If over the course of the legal hold the records meet their retention, they should be destroyed per the disposition processes of the institution. If they still have ongoing retention purposes, they must be held onto until those have been met.
2. Electronic Records
  1. When the legal hold affects electronic records, if the system the records are in can place the records on hold, that should be done as soon as the OGC lets the department know of the hold on the records.
  2. If the system holding the records does not have an automated process, records should be pulled out of the system and quarantined into another space where they can stay in suspension until the legal hold has passed.
3. Physical Records
  1. When physical records are affected, the holder of the record must be notified so disposition can be suspended (e.g., if they are being archived by the Church History Department, the Records Manager must be notified of the hold). The OGC may want all the applicable records delivered to them, in which case appropriate persons must be notified so the transfer can be authorized.
Email Management
1. Guidelines for Emails
  1. Emails often contain information subject to retention as well as sensitive information that should not be retained. As such the following guidelines should be followed:
    1. Emails that are identified as records should be moved out of the institution’s email system and into an institution-approved electronic records repository.
      1. This can be done by creating records folders in employee’s email inboxes that manage retention or transfer records to the electronic records repository.
    2. Institutions should determine a retention for non-essential emails and then implement automated deletion of emails not moved into records folders.
      1. Retention of emails should not be so stringent employees feel the need to save unnecessary information for fear of losing important non-record information.
    3. Once automated deletion is decided upon, training should be provided to the institution’s employees to spread awareness.
    4. Email management not only clears important institution server space by deleting unnecessary emails, but in the event of a legal/litigation hold saves the institution time and money searching for relevant information in email inboxes.
Maturing the Program
1. Recurring Audits
  1. In partnership with the CPC, a periodic audit or gap analysis of these procedures should occur. Findings should be evaluated, risks identified, and remediation should occur as needed.
2. Program Optimization
  1. The RIM Program should be built out in a systematic way. This means the above activities move from an ad-hoc formation to repeatable, from repeatable to defined, from defined to mature and eventually become optimized mitigating risk and liability.
  2. Moving towards optimization should be done in a strategic manner with roadmaps built out each year as the appropriate changes take place. All of this should be done in compliance with CES Privacy guidelines and the institution’s Security and Compliance standards.
3. Automation
  1. Automation should be added to processes where possible. Automation takes processes from relying entirely on employees and persons to move and dispose of records/data to relying on systems to do those processes. This should be done where it makes sense and where possible within the institution’s systems.
RIM Program Resources
1. Intranet
  1. These procedures correspond with the Records and Information Retention Policy and the CES GRS . These documents can be found the Ensign College Intranet.
  2. Retention information should be behind the institution’s firewall or applicable login mechanism. All employees are required to have access to the Records and Information Retention Policy.
  3. Additionally, each department must have access to their individual RMP and should be trained on it at least annually.
2. Related Information
  1. Records and Information Retention Policy
  2. CES General Retention Schedule
  3. RIM Program Summary
  4. Records Management Plan
    1. Department level
    2. Institution level

APPROVED DATE: March 8, 2024

APPLICABILITY: This policy applies to all institution departments and records created or maintained by the institution.

PROCEDURES STEWARD: Director of Learning Resources

PROCEDURES OWNER: Chief Information Officer

RELATED POLICIES / PROCEDURES:

NOTES: Record and Information Retention Program Summary

Approval Date

08 March 2024

Applicability

This policy applies to all institution departments and records created or maintained by the institution.

Policy Owner

Chief Information Officer

Policy Steward

Director of Learning Resources

Related Policies or Procedures