Improper Disclosure Reporting Form
Parents, eligible students (students who are at least 18 years of 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 using this form. 

Please do NOT include any information in this form that would constitute student personally identifiable information.
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First Name *
Last Name *
Phone Number *
Email Address *
Role/Relationship to Student *
What is your affiliation (community member, building you work in/student attends)?
 *
Description of event(s) that lead you to believe an improper disclosure or breach has occurred:
 *
Description of the possible disclosed data:
 *
Description of how the reporter learned of the possible disclosure:
 *
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