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Information System Inventory Form



1. SYSTEM TITLE
  		2. SYSTEM CONTROL NUMBER
 
3. AGENCY PROGRAM SUPPORTED BY SYSTEM
  		4. PROGRAM AUTHORITY
 
 5. SYSTEM DESCRIPTION
 
5A. PURPOSE/FUNCTION OF SYSTEM




5B. SOURCE(S) OF DATA (Include inputs from other systems)



5C. INFORMATION CONTENT





5D. SYSTEM OUTPUTS (Include outputs from other systems)
6. NAME AND ADDRESS OF PRINCIPAL PROGRAM OFFICE SUPPORTED BY THE SYSTEM (Include room numbers)
7. AGENCY CONTACTS (Names, addresses, and phone numbers of system and program personnel who can provide additional information about the system and the program it supports.)
8. PREVIOUS DISPOSITION JOBS
9A. PREPARER'S NAME
  		9B. OFFICE NAME AND ADDRESS
 
9C. PHONE NUMBER
 
SIGNATURE
  		DATE

NA FORM 14028 (9-88)

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