Role/Relationship to the District (i.e. parent/guardian, student, teacher, staff, etc.) *
Your answer
Building Affiliation *
Required
Please Select the Date the Violation Occurred *
MM
/
DD
/
YYYY
Please list the name of the individual(s) involved. If you are listing multiple names, please separate each name with a semi colon (for example: John Smith; Jane Jones). *
Your answer
Please select the type(s) of Personally Identifiable Information (PII) disclosed. If an item is not on the list, you will have the opportunity to list the item(s) in response to the next question. *
Required
Description of the Event(s)
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.”)
*
Your answer
Description of How Reporter Learned of the Possible Disclosure * *
Your answer
Please provide the names and contact information for any additional individuals who may be able to provide supporting information. *
Your answer
Please provide any additional information you feel necessary to complete your complaint. *