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Protecting the Privacy of Student Records
Exhibit 6-3
Sample Affidavit of Non-Release
by Researchers 

I, [name of individual], do solemnly [swear or affirm] that when given access to the [title of data to be provided] provided by [name of the agency or school], I shall not:

Signature: ______________________________________

Name: _________________________________________

Title: __________________________________________

Organization: ____________________________________

Date: __________________________________________

The penalty for unlawful release is [maximum penalties as specified by the applicable laws and provide citations].

Notary Public and Seal: ____________________________

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