REPORT AN IMPROPER DISCLOSURE

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GENERAL INSTRUCTIONS:

Please do NOT include any information in this form that would constitute student personally identifiable information (PII).** SED will contact you if additional information is needed.

By filing this form, you are filing a complaint with the Chief Privacy Officer alleging that PII has been disclosed to or accessed by an unauthorized person.

If you are an educational agency seeking to report a breach or unauthorized disclosure of PII, do not complete this form. Please complete the Data Incident Reporting Form instead.

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 or attending a postsecondary institution at any 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 is preferred that the complaint identify the person making the complaint (complainant). Please note that it may be impossible to properly investigate or respond to an anonymous complaint if the original complaint does not provide enough information and does not provide an individual contact who can supplement or clarify the information submitted.

Q: Will a third party named in a complaint be contacted by the Chief Privacy Officer?

A: Third parties named in a complaint will be contacted and the contents and details of the complaint disclosed. The complainant's identity will be disclosed if it is necessary to complete the investigation and review.

Q: What happens after I file this complaint?

A: The complaint will be reviewed by:

Chief Privacy Officer
NYS Education Department
89 Washington Avenue
Albany, NY 12234

** 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

First name *

Fill in None to remain anonymous. Please note that anonymous submissions must contain a sufficient amount of information to investigate.

Last name *

Fill in None to remain anonymous. Please note that anonymous submissions must contain a sufficient amount of information to investigate.

Phone number (XXX-XXX-XXXX) *

Fill in 999-999-9999 to remain anonymous. Please note that anonymous submissions must contain a sufficient amount of information to investigate.

Email address *

Fill in data@jerichoschools.org to remain anonymous. Please note that anonymous submissions must contain a sufficient amount of information to investigate.

Role of Individual or Entity Making the Complaint *

Parent/Guardian

Student

Principal

Teacher

Central Office Administrator

Building Administrator

Required

Date Violation Occurred *

YYYY

Name of Individual(s) Involved *

Name of School District/Organization(s) Involved *

Please describe the specific Personally Identifiable Information (PII) that was disclosed. *

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.”)

Please describe how the specific Personally Identifiable Information (PII) was disclosed. *

Please provide the names and contact information for any additional individuals who may be able to provide supporting information. *

Please describe whether you contacted any school official(s) in an attempt to discuss or resolve this matter. Please explain. *

Please provide any additional information you feel necessary to complete your complaint. *

Certification: I certify that the information I have provided is true to the best of my knowledge. *

Yes

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