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Forum Guide to Protecting the Privacy of Student Information: State and Local Education Agencies

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Exhibit 52: Sample Request to Review an Education Record



Date:_____________________

To:      [Name of Designated Official]

From:  [Name of Parent]

          [Address and Phone Number]

Under the provisions of the Family Educational Rights and Privacy Act and [insert applicable state/local laws and regulations], I wish to inspect the following education record:

_________________________________________________________

_________________________________________________________

_________________________________________________________

of [Name of Student]:_____________________

School at Which Student Is Enrolled:_____________________

Requester(s) Relationship to Student:_____________________

I do __/do not ___ desire a copy of such records. I understand that a reasonable fee will be charged for the copies.

[Insert fee schedule if available]

Signature:_____________________


For Official Use Only

Date Received: _______

Date Request Verified: _______ Verified by: _______

Approved: ___ Disapproved: ___ Reason(s) for disapproval:_____________________

Signature of Official Approving/Disapproving Request:_____________________

Date: _______ Date Notification Sent: _______

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National Center for Education Statistics - http://nces.ed.gov
U.S. Department of Education