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Protecting the Privacy
of Student Records
Exhibit 5-2
Sample Request to Review
an Education Record
of [Name of Student]:
School At Which Student is Attending:
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.
......................................................................................................................................................
For official use only
Date: _______________________
To: [Name of Designated Official]
From: [Name of Parent(s)]
[Address and Phone Number]
Under the provisions of the Family Educational
Rights and Privacy Act of 1974 and [insert applicable state/local laws
and regulation], I wish to inspect the following education record:
of [Name of Student]:
School At Which Student is Attending:
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.
Signature:
......................................................................................................................................................
For official use only
Date Received: _____________Date Request Verified: ____________
Approved:____Disapproved:_____Reason(s) for disapproval:____________________________
Signature of Official Approving/Disapproving Request:_________________________________
Date: ________________ Date Notification Sent: __________________
For questions about the content of this product, please contact
Lee
M. Hoffman.
