Complaint Regarding a Potential Breach or Unauthorized Release of Personally Identifiable Information
Pursuant to Educational Law 2-d, "each educational agency must establish and communicate to parents and eligible students procedures for parents and eligible students to file complaints about breaches or unauthorized releases of student data."  Upon submission of this form, we will provide you with acknowledgement of receipt, commence an investigation, and take the necessary precautions to protect any personally identifiable information. A report of our findings will be provided within a reasonable time period.  Should we need more time we will provide you with a written explanation that includes the approximate date when we anticipate that the report will be released.
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First Name *
Last Name *
Phone Number *
Role *
Name(s) of person involved *
Name of school involved *
Description of student data compromised *
Description of improper disclosure *
Contacts for additional information (List names and telephone numbers/email of individuals who can provide additional information) *
Have you contacted any school official in an attempt to resolve this matter? If so, whom? What occurred? *
Please provide any additional information in regards to this complaint. *
I certify that the information I have provided is true to the best of my knowledge. *
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