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Charlotte Valley Central School - Report an Improper Disclosure
GENERAL INSTRUCTIONS:
Please do NOT include any information in this form that would constitute student or teacher of principal personally identifiable information (collectively referred to as "PII").** Charlotte Valley CSD will contact you if additional information is needed.
By filing this form, you are filing a complaint with the Charlotte Valley District Privacy Coordinator alleging that PII has been disclosed to or accessed by an unauthorized person.
Please complete the form thoroughly, including sufficient detail that will allow the complaint to be investigated.
FREQUENTLY ASKED QUESTIONS:
Q: Who may file a complaint?
A: A complaint may be made by a parent or parents of a student, eligible student (a student who is at least 18 years of age), principals, teachers, and employees of an educational agency.
Q: May a complaint be filed anonymously?
A: An anonymous complaint will be accepted and investigated if it contains enough information regarding the nature of the complaint and the parties involved. It may be impossible to properly investigate or respond to an anonymous complaint because Charlotte Valley CSD cannot contact the person who filed it and may need additional information. Additionally, sometimes the person making the complaint (the "complainant") and the circumstances of the complaint are well-known to the school, making it impossible to maintain a complainant's anonymity.
Q: Will a third party named in a complaint be contacted by the District?
A: Third parties named in a complaint will be contacted and the contents and details of the complaint will be disclosed.
Q: What happens after I file this complaint?
A:
You will receive follow-up from the District.
The complaint will be reviewed by:
District Privacy Officer
Charlotte Valley CSD
15611 State Route 23
Davenport, NY 13750
After Charlotte Valley CSD review is completed, you will receive an email informing you of the action(s) taken as a result of your complaint.
**PII (Personally Identifiable Information) is generally defined as any data from the student records of an educational agency that could potentially be used, alone or in combination with other data elements, to identify a particular student, or teacher or principal annual professional performance review (APPR) data. For more information on FERPA (Family Educational Rights and Privacy Act), which is the federal law that protects the privacy of student education records, go here:
www2.ed.gov/ferpa
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* Indicates required question
Please list your first name.
Your answer
Please list your last name.
Your answer
Please list your phone number (xxx-xxx-xxxx).
Your answer
Please list your e-mail address.
*
Your answer
Please select the role of individual or entity making the complaint.
*
Parent/Guardian
Student
Eligible Student
Teacher
Educational Agency Employee
Please select the date that the violation occurred.
*
MM
/
DD
/
YYYY
Please list the name of the i
ndividual(s) involved. If you are listing multiple names, please separate each name with a semi colon (for example: John Smith; Jane Jones).
Your answer
Please list the name of the
school district/organization(s) involved. If you are listing multiple school districts or organizations, please separate each name with a semi colon (for example: Little CSD; Tiny School).
Your answer
Please select the type(s) of Personally Identifiable Information (PII) disclosed. If an item is not on the list, you will have the opportunity to list the item(s) in response to the next question.
*
Parent Address
Parent Name(s)
Student Address
Student Grades
Student ID Number
Student IEP Information
Student Name
Student Phone Number
Student Picture
Required
Please describe the specific PII that was disclosed and not listed above. Please separate each item with a semi colon.
IMPORTANT: Please do not reference the actual PII that was disclosed. Please only reference the PII by name (i.e. “the student's social security number” or “the student's birth date.”)
Your answer
Please describe how the specific Personally Identifiable Information (PII) was disclosed.
*
Your answer
Please provide the names and contact information for any additional individuals who may be able to provide supporting information.
Your answer
If you contacted any school official(s) in an attempt to discuss or resolve this matter, please describe what happened.
Your answer
Please provide any additional information you feel necessary to complete your complaint.
Your answer
Do you want Charlotte Valley CSD Privacy Office to keep your name and contact information confidential? Some complaints may not be able to be investigated if the complainant seeks to remain confidential.
*
Yes
No
Certification: I certify that the information I have provided is true to the best of my knowledge.
*
YES, I certify that the information I have provided is true to the best of my knowledge.
NO, I do not certify that the information I have provided is true to the best of my knowledge.
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