Island Park UFSD Unauthorized Data Disclosure Report Form

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A report of unauthorized data disclosure can be submitted by a parent/guardian or parents/guardians of a student, an eligible student (a student who is at least 18 years of age or attending a postsecondary institution at any age), principals, teachers, and employees of an educational agency. Please limit the amount of personally identifiable information shared when completing this form.

Email *

CONTACT INFORMATION

1. Last Name *

2. First Name *

3. Email Address *

4. Phone Number *

5. Please select the role that best represents the person submitting this form.

PLEASE PROVIDE THE DETAILS OF THE UNAUTHORIZED DISCLOSURE HERE

6. Please enter the date when the unauthorized disclosure occurred or was discovered. *

YYYY

7. Please share what parties were impacted by the disclosure. *

8. Please describe what data was disclosed to the best of your ability. Separate data types by a semicolon. Example: Demographic data; Health data; Ethnicity data *

9. Please add any additional information you feel is relevant here.

REPORT AN UNAUTHORIZED DATA DISCLOSURE TO THE NYSED PRIVACY OFFICE

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 or attending a postsecondary institution at any age), principals, teachers, and employees of an educational agency.

By filing this form, you are filing a complaint with the Chief Privacy Officer alleging that Personally Identifiable Information (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.

Click here to access the Report an Improper Disclosure form.

(https://forms.office.com/Pages/ResponsePage.aspx?id=6BbvFeBMw0-S4mp6bI52Xiu3S0TIErdCsyh9u-tAGK5UQ000RllLVjFUMFVWRVVCTEtOMzVOMEVTRCQlQCN0PWcu)

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