Unauthorized Disclosure Complaint Form
Parents, eligible students (students who are at least 18 years of age or attending a post-secondary 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.
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Email *
First Name *
Last Name *
Contact Phone Number *
Role/Relationship to the District (i.e. parent/guardian, student, teacher, staff, etc.) *
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). *
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.”)
 *
Description of How Reporter Learned of the Possible Disclosure * *
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. *
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