Unauthorized Disclosure Complaint Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Parents/guardians, eligible students (students who are at least 18 years of age or attending a postsecondary institution at any age), principals, teachers, and employees of an educational agency may file a complaint about a possible breach or improper disclosure of student data and/or protected teacher or principal data.

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

Please list your first name *

Please list your last name *

3. Please list your phone number (xxx-xxx-xxxx) *

4. Please list your e-mail address *

Please select the role of individual or entity making the complaint *

Parent/Guardian

Student

Eligible Student

Principal

Teacher

District Employee

6. Date that the disclosure occurred: - Please input date (mm/dd/yyyy) *

YYYY

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). *

Please list the name of the specific school involved *

Please select the type(s) of Personally Identifiable Information (PII) disclosed. *

Parent Address

Parent name(s)

Student Grades

Student ID number

Student IEP Information

Student Name

Student Phone Number

Student Picture

Other:

Required

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 *

If you contacted any school official(s) in an attempt to discuss or resolve this matter, please describe what happened *

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

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of West Seneca Central School District. Report Abuse

Forms