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).** The District's Data Privacy Officer will contact you if additional information is needed.

By filing this form, you are filing a complaint with the Data Privacy Officer alleging that 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.

Email *

First name *

Last Name *

Phone Number *

Role of Individual or Entity Making the Complaint *

Parent/Guardian

Student

Eligible Student

Principal

Teacher

Superintendent

Other:

Date Violation Occurred *

YYYY

Name of Individual(s) Involved

Name of School(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 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, I certify that the information I have provided is true to the best of my knowledge.

NO, I do not certify that the information I have provided is true to the best of my knowledge.

Send me a copy of my responses.

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