- Surveys & Programs
- Data & Tools
- Fast Facts
- News & Events
- Publications & Products
- About Us
- Preface
- Acknowledgments
- Task Force Members
- 1: An Overview
- 2: Summary of Key Federal Laws
- 3: Protecting the Privacy of Individuals During the Data Collection Process
- 4: Securing the Privacy of Data Maintained and Used Within an Agency
- 5: Providing Parents Access to Their Child's Records
- 6: Releasing Information Outside an Agency
- List of Exhibits & Figures
- List of Acronyms
PDF & Related Info
Ghedam Bairu
Return to List of Exhibits and Figures
Exhibit 6–5: Sample Statement of Nonrelease of Released Information
I understand that upon receipt of the information provided by [name of agency or school] regarding [type of information] about [name of student(s)], the re-release of such information is prohibited by the Family Educational Rights and Privacy Act of 1974, as amended [and cite state and local laws, where applicable]. I acknowledge that I fully understand that the intentional release by me of this information to any unauthorized person could subject me to [criminal and civil penalties, where applicable] imposed by law.
Signature: _________________________________
Name: _________________________________
Title: _________________________________
Organization: _________________________________
Date: _________________________________