Return to List of Exhibits and Figures

Exhibit 5–2: 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: _______

Return to List of Exhibits and Figures

Top