Data Retention and Disposal Policy (OP-POL-003)

1. Objective

The objective of this policy is to establish comprehensive requirements for the retention, archival, and secure disposal of [Company Name]’s information assets throughout their lifecycle. This policy ensures that information is retained for appropriate periods to meet business, legal, and regulatory requirements, particularly for electronic Protected Health Information (ePHI), while ensuring secure disposal when information is no longer needed, in compliance with HIPAA, HITECH, state privacy laws, and SOC 2 requirements.

2. Scope

This policy applies to all [Company Name] workforce members, contractors, and third parties who create, process, store, or dispose of company information. It encompasses all information in any format (electronic, physical, audio, video) and storage medium (databases, file systems, email, backup media, cloud storage, paper documents, optical media). This policy covers all phases of the information lifecycle from creation through final disposition, including active use, archival storage, and secure destruction.

3. Policy

[Company Name] shall implement systematic data retention and disposal practices that balance business needs, legal requirements, regulatory compliance, and security considerations.

3.1 Data Retention Framework

All information assets shall be subject to defined retention periods based on their type, sensitivity, regulatory requirements, and business value. These periods shall be formally documented in the official [Company Name] Data Retention Schedule.

3.1.1 Data Retention Schedule

The Records Manager, in coordination with the Retention Committee, shall develop and maintain a formal Data Retention Schedule. This schedule is the official source of truth for all data retention periods and shall be reviewed and approved annually by the Retention Committee. The schedule shall, at a minimum, categorize data types and assign a specific, non-ambiguous retention period for each. Examples of categories include:

  • Corporate Governance: Records related to the legal and operational structure of the company.
  • Financial and Tax: Records required for financial reporting and tax compliance.
  • Personnel Records: Information related to employees and human resources.
  • Contracts and Agreements: Legal agreements with customers, vendors, and partners.
  • Electronic Protected Health Information (ePHI): Health data subject to HIPAA and state laws.
  • Operational Data: General business records, correspondence, and system data.

3.1.2 Electronic Protected Health Information (ePHI) Retention

ePHI shall be retained in accordance with HIPAA requirements and applicable state laws, as specified in the Data Retention Schedule:

  • Minimum Retention Period: All policies, procedures, and other documentation required by the HIPAA Security Rule shall be retained for a minimum of six (6) years from the date of their creation or the date when they were last in effect, whichever is later. State-specific laws may require longer retention periods.
  • Extended Retention: ePHI for minors shall be retained in accordance with applicable state laws, as documented in the Data Retention Schedule.
  • Research Records: ePHI used in research retained per research protocol requirements
  • Legal Hold: ePHI subject to litigation hold retained until legal matter resolution
  • State Requirements: Compliance with state-specific retention requirements where more stringent

3.1.3 Backup and Archive Retention

  • Operational Backups: Retained for [Duration, e.g., 30 days] for immediate recovery needs
  • Monthly Archives: Retained for [Duration, e.g., 12 months] for historical recovery
  • Annual Archives: Retained per data classification retention requirements
  • Legal Hold Archives: Retained until legal matter resolution and hold release
  • Disaster Recovery Archives: Maintained at geographically separate locations

3.2 Legal Hold and Litigation Support

Special procedures shall govern information retention when legal proceedings are anticipated or active.

3.2.1 Legal Hold Procedures

  • Legal hold notices shall be issued immediately upon notification of potential litigation
  • All relevant custodians shall be notified and acknowledge receipt of legal hold instructions
  • Automated deletion processes shall be suspended for information subject to legal hold
  • Legal hold inventory shall be maintained documenting preserved information
  • Regular legal hold reminders shall be sent to ensure ongoing compliance

3.2.2 eDiscovery Support

  • Information systems shall be capable of identifying, preserving, and producing relevant information
  • Search and collection capabilities shall be maintained for electronic information
  • Chain of custody procedures shall be followed for all collected information
  • Metadata preservation shall be maintained during collection and production processes
  • Privileged information shall be identified and protected during discovery processes

3.3 Data Disposal Framework

Information shall be securely disposed of when retention periods expire or when no longer needed for business purposes.

3.3.1 Disposal Triggers

Information disposal shall be triggered by:

  • Expiration of defined retention periods
  • Completion of business processes requiring the information
  • System decommissioning or migration activities
  • Employee termination (personal information only)
  • Contract termination with appropriate notice periods
  • Legal hold release after litigation conclusion

3.3.2 Disposal Classification Requirements

Disposal methods shall correspond to information sensitivity levels:

Public Information:

  • Standard deletion or disposal methods acceptable
  • No special security requirements
  • Standard recycling procedures for physical media

Internal Information:

  • Secure deletion using approved software tools
  • Physical media shredding or incineration
  • Verification of deletion completion

Confidential Information:

  • Cryptographic erasure or secure overwriting (minimum 3 passes)
  • Cross-cut shredding for physical documents
  • Degaussing for magnetic media
  • Certificate of destruction required for third-party disposal

Restricted Information (including ePHI):

  • Cryptographic erasure using approved methods
  • Physical destruction for all storage media
  • Witnessed destruction with certificates of completion
  • Chain of custody documentation throughout disposal process
  • Hardware Security Module (HSM) secure deletion for cryptographic keys

3.4 Secure Disposal Methods

Specific disposal methods shall be employed based on media type and information sensitivity.

3.4.1 Electronic Media Disposal

Hard Disk Drives:

  • Software-based secure deletion using NIST SP 800-88 approved methods
  • Cryptographic erasure where full disk encryption is implemented
  • Physical destruction for Restricted information or failed drives
  • Degaussing using approved degaussing equipment

Solid State Drives (SSDs):

  • Cryptographic erasure preferred method
  • Manufacturer secure erase commands
  • Physical destruction for high-sensitivity information
  • Verification of successful deletion

Removable Media:

  • Physical destruction for all Confidential and Restricted information
  • Secure overwriting for reusable media containing less sensitive information
  • Degaussing for magnetic media (tapes, floppy disks)

Mobile Devices:

  • Factory reset combined with encryption
  • Physical destruction of storage components for Restricted information
  • Remote wipe verification for lost or stolen devices
  • Removal of SIM cards and memory cards

3.4.2 Physical Document Disposal

  • Cross-cut shredding with particle size [Size, e.g., 4mm x 32mm] or smaller
  • Incineration for highly sensitive documents
  • Pulping for large volumes of confidential documents
  • Witnessed destruction for Restricted information

3.4.3 Cloud Data Disposal

  • Cryptographic erasure using customer-managed encryption keys
  • Verification of data deletion from all storage tiers and backups
  • Certificate of deletion from cloud service providers
  • Contractual guarantees for secure disposal processes

3.5 Disposal Documentation and Verification

All disposal activities shall be documented and verified to ensure completeness and compliance.

3.5.1 Documentation Requirements

Disposal records shall include:

  • Description of information or systems disposed
  • Disposal method used and justification
  • Date and time of disposal activities
  • Personnel involved in disposal process
  • Verification of successful disposal
  • Certificates of destruction from third-party vendors
  • Chain of custody documentation

3.5.2 Verification Procedures

  • Independent verification of disposal completion
  • Random sampling and testing of disposal processes
  • Third-party validation for high-sensitivity disposals
  • Photographic evidence for physical destruction
  • Digital signatures for electronic disposal certificates

3.6 Third-Party Disposal Services

External disposal services shall meet [Company Name] security requirements and provide appropriate assurances.

3.6.1 Vendor Requirements

  • Security assessment and approval before engagement
  • Appropriate certifications (e.g., NAID AAA, R2, e-Stewards)
  • Comprehensive insurance coverage for data breaches
  • Signed confidentiality and security agreements
  • On-site destruction capabilities or secure chain of custody

3.6.2 Vendor Oversight

  • Regular audits of disposal vendor processes
  • Witness disposal activities for high-sensitivity information
  • Validation of certificates of destruction
  • Incident reporting requirements for disposal failures
  • Performance monitoring and contract compliance reviews

3.7 Data Retention Governance

Formal governance processes shall ensure consistent application of retention and disposal policies.

3.7.1 Retention Committee

  • A cross-functional committee including Legal, Compliance, IT, and Records Management shall be maintained.
  • The committee shall meet at least quarterly to review retention and disposal activities.
  • The committee is responsible for the annual review and formal approval of the Data Retention Schedule and this policy.
  • Resolution of retention conflicts and exceptions
  • Approval of retention schedule modifications

3.7.2 Records Management Program

  • A designated Records Manager shall be responsible for program oversight.
  • The Records Manager is responsible for the maintenance, accuracy, and communication of the official Data Retention Schedule.
  • Training programs for workforce members
  • Compliance monitoring and reporting
  • Technology solutions for automated retention management

3.8 Monitoring and Compliance

Regular monitoring shall ensure adherence to retention and disposal requirements.

3.8.1 Compliance Monitoring

  • Automated monitoring of retention periods and disposal triggers
  • Regular audits of disposal activities and documentation
  • Compliance reporting to management and regulators
  • Exception reporting and corrective action procedures
  • Key performance indicators (KPIs) for retention and disposal programs

3.8.2 Training and Awareness

  • Annual training on retention and disposal requirements
  • Role-specific training for records custodians
  • New employee orientation including retention policies
  • Regular communications on policy updates
  • Testing and validation of training effectiveness

4. Standards Compliance

This policy is designed to comply with and support the following industry standards and regulations.

Policy Section Standard/Framework Control Reference
3.1.2 HIPAA Security Rule 45 CFR § 164.308(a)(4)(ii)(A) - Information Access Management
3.3, 3.4 HIPAA Security Rule 45 CFR § 164.310(d)(2)(i) - Media Disposal
3.1.2 HIPAA Privacy Rule 45 CFR § 164.530(j)(2) - Record Retention
3.4 NIST SP 800-88 Guidelines for Media Sanitization
All SOC 2 Trust Services Criteria CC6.5 - Data Disposal
3.7 SOC 2 Trust Services Criteria CC2.1 - Communication and Information
3.8 SOC 2 Trust Services Criteria CC4.1 - Monitoring Activities
All ISO/IEC 27001:2022 A.8.3 - Media Handling

5. Definitions

Chain of Custody: Documentation of the chronological transfer of evidence or information from collection to disposal.

Cryptographic Erasure: Data destruction method that renders data unrecoverable by destroying encryption keys.

Degaussing: Process of reducing or eliminating magnetic fields from magnetic storage media.

eDiscovery: Process of identifying, preserving, and producing electronically stored information for legal proceedings.

Legal Hold: Suspension of normal records disposal to preserve information that may be relevant to litigation.

Media Sanitization: Process of removing information from storage media such that recovery is not feasible.

Retention Schedule: Documented plan specifying how long different types of records should be kept.

Secure Deletion: Method of data destruction that makes recovery of deleted data infeasible.

6. Responsibilities

|Role|Responsibility| |—|—| |Records Manager|Develop and maintain retention schedules, oversee disposal activities, coordinate legal holds, and ensure compliance with retention policies.| |Legal Team|Establish legal retention requirements, issue legal hold notices, support eDiscovery activities, and ensure compliance with legal obligations.| |Privacy Officer|Ensure ePHI retention complies with HIPAA requirements, oversee privacy-related disposals, and coordinate with legal team on privacy matters.| |IT Security Team|Implement secure disposal technologies, verify disposal completion, manage disposal vendors, and ensure security of disposal processes.| |System Administrators|Execute disposal procedures, maintain disposal documentation, implement automated retention controls, and support legal hold activities.| |Information Owners|Determine business retention requirements, approve disposal activities, participate in retention reviews, and ensure appropriate information handling.| |Compliance Team|Monitor retention compliance, conduct disposal audits, report compliance status, and coordinate regulatory requirements.| |All Workforce Members|Comply with retention requirements, participate in legal holds, properly dispose of information, and report retention violations.| |Audit Team|Conduct retention and disposal audits, validate compliance with policies, review disposal documentation, and report audit findings.| Legal Hold: Suspension of normal records disposal to preserve information that may be relevant to litigation.

Media Sanitization: Process of removing information from storage media such that recovery is not feasible.

Retention Schedule: Documented plan specifying how long different types of records should be kept.

Secure Deletion: Method of data destruction that makes recovery of deleted data infeasible.

6. Responsibilities

Role Responsibility
Records Manager Develop and maintain retention schedules, oversee disposal activities, coordinate legal holds, and ensure compliance with retention policies.
Legal Team Establish legal retention requirements, issue legal hold notices, support eDiscovery activities, and ensure compliance with legal obligations.
Privacy Officer Ensure ePHI retention complies with HIPAA requirements, oversee privacy-related disposals, and coordinate with legal team on privacy matters.
IT Security Team Implement secure disposal technologies, verify disposal completion, manage disposal vendors, and ensure security of disposal processes.
System Administrators Execute disposal procedures, maintain disposal documentation, implement automated retention controls, and support legal hold activities.
Information Owners Determine business retention requirements, approve disposal activities, participate in retention reviews, and ensure appropriate information handling.
Compliance Team Monitor retention compliance, conduct disposal audits, report compliance status, and coordinate regulatory requirements.
All Workforce Members Comply with retention requirements, participate in legal holds, properly dispose of information, and report retention violations.
Audit Team Conduct retention and disposal audits, validate compliance with policies, review disposal documentation, and report audit findings.