Form 1.

The following information is required to be filed with the State Secretary for compliance with the Fair Information Practices Act.

AGENCY: ________________ EXECUTIVE OFFICE __________________________________________________________

PERSON RESPONSIBLE FOR SYSTEM: ____________________________________________________________________

TITLE: _________________ BUSINESS ADDRESS: ___________________________________________________________

SYSTEM NAME: ________________________________________________________________________________________

NATURE AND PURPOSE OF SYSTEM: _____________________________________________________________________

________________________________________________________________________________________________________

CATEGORIES OF DATA; NUMBER OF DATA SUBJECTS WITHIN CATEGORIES: _______________________________

IS SYSTEM AUTOMATED: YES _____ NO _____ PARTIALLY ________________________________________________

IF AUTOMATED OR PARTIALLY SO, DESCRIBE: ___________________________________________________________

METHODS OF STORAGE: ________________________________________________________________________________

RETENTION AND DISPOSITION SCHEDULES: (as approved by the Records Conservation Board)__________________________________________________________________________________________________

CATEGORIES OF DATA SOURCES: _______________________________________________________________________

CATEGORIES OF DATA ELEMENTS: ______________________________________________________________________

Form 1. (continued)

USES OF DATA AND DESCRIPTION OF CLASSES OF USERS:_________________________________________________

DISCLOSURES OUTSIDE AGENCY: _______________________________________________________________________

ACTIONS TAKEN TO COMPLY WITH CHAPTER 66A: _______________________________________________________

SIGNATURE __________________________________________________________

REGULATORY AUTHORITY

950 CMR 33.00: M.G.L. c. 66A.