STATE OF OKLAHOMA

ARCHIVES AND RECORDS COMMISSION

OPTICAL IMAGING ANNUAL COMPLIANCE REPORT
Page  ______  of  ______
	
1.	Name of Agency

	2.	Year Covered by Report

3.	Name of Person Who Compiled Report

	4.	Date Report was Compiled	
5.	

_________________________________________________
Signature of Person who Compiled Report
	6.	If not an agency employee, list firm name, address, and telephone number.

	
7.	Name of Person Submitting Report

	8.	Telephone Number of Person Submitting Report	
9.	Name of Optical Imaging System Administrator

	10.	If not an agency employee, list firm name, address, and telephone number.

	
11.	List below all agency records with an approved retention period of ten (10) years or more maintained in optical imaging format:	

Schedule Number(s)	
Series Number(s)	
Title(s)	

			
12.	I hereby certify that for the above listed records, during the period covered by this report, to the best of my knowledge, the

____________________________________________________________

complied with all applicable Archives and Records Commission Rules relating to records maintained in optical imaging systems.	

__________________________________________________
13.	Signature of Person Submitting Report

______________________________________________
14.	Date

__________________________________________________
15.	Received by	

______________________________________________
16.	Date	
ARC Form 15
Rev.    07/99	
OPTICAL IMAGING ANNUAL COMPLIANCE REPORT INSTRUCTIONS

1.	The official name of the agency whose records are covered by the report.
2.	The fiscal year covered by the report.
3.	The name of the person who compiled the report.  This may or may not be the same individual who certifies the report .  When agencies have contracted with a vendor to provide imaging services, this person can be either a representative of the vendor or an employee of the agency.

4.	The date the report was compiled.
5.	The signature of the person who compiled the report.  This may or may not be the same individual who certifies the report.  When agencies have contracted with a vendor to provide imaging services, this person can be either a representative of the vendor or an employee of the agency.

6.	If the agency has contracted with a vendor to provide imaging services, list the vendor's firm or agency name, address, and telephone number.

7.	The name of the person who is stating that the information contained in the report is to the best of his/her knowledge accurate.  This individual must be an official or employee of the agency submitting the report, regardless of whether the records are being imaged by the agency or a vendor.

8.	The telephone number of the person submitting the information contained in the report.
9.	The name of the person who serves as the systems administrator for the system being used to image the agency's records.  In the case of agencies who have contracted with a vendor to provide imaging services, in all likelihood, this person will be a representative of the vendor and not an employee of the agency.

10.	If the systems administrator is not an employee of the agency, list the applicable firm or agency name and his/her address and telephone number.

11.	The records disposition schedule number(s), series number(s), and title(s) of all records with an approved retention period of ten (10) years or more maintained in optical imaging systems in accordance with dispositions approved by the Archives and Records Commission.

12.	The official name of the agency whose records are covered by the report.
13.	The signature of the person stating that the information contained in the report is to the best of his/her knowledge accurate.

14.	The date the person in No. 13 signed the report.
15.	The signature of the State Records Administrator or his/her designee.
16.	The date the State Records Administrator or his/her designee signed the report.

Submit this form to:
State Records Administrator
Oklahoma Department of Libraries
200 N.E. 18th Street
Oklahoma City, Oklahoma 73105