Ferpa Records Restriction Form printable pdf download

FERPA Records Restriction Form

Registrar’s Office

160 East Tenth Street, Claremont, CA 91711 ● Phone (909) 621-8285 ● Fax (909) 607-7285

The federal Family Educational Rights and Privacy Act (1974) guarantees students the right to have some control over the disclosure

of personally identifiable information from their education records. Students in attendance may request that the University restrict

disclosure of their information in one of two ways. (1) Directory restrictions affect the disclosure of certain directory information items.

(2) FERPA restrictions are requests to restrict all of a student’s information and require the concurrence of the Registrar.

Directory information is information that can be disclosed without the student’s prior consent. CGU designates the following student

data as directory information: name; e-mail address; degree/certificate program of study; concentration of study; dates of attendance;

and degrees or certificates received and their conferral date.

Restrictions remain in effect until revoked by the individual in writing. When a request to release a restriction is not made in person, a

photocopy of the individual’s current ID—a driver’s license or passport—should accompany the written request.

FERPA does not require that the University accept restrictions requests from individuals who are not current students in attendance;

however, such requests will be considered on an individual basis. Where excepted by FERPA, disclosures of personally identifiable

information may be permitted even if a student has placed a restriction on disclosures.

Questions about restricting the disclosure of student information should be directed to the Registrar’s Office.

Student Information

CGU ID# 254- (optional)___________________________________________

Last Name

______ First Name

_____

Academic Department

______ Degree Program

____________

TO PLACE A RESTRICTION ON THE DISCLOSURE OF INFORMATION

I hereby request that the University restrict (select one) □ my directory □ all my information from disclosure without my prior writ-

ten consent. I understand that this restriction will remain in effect until I provide written instructions to the University to revoke this re-

quest. Further, I acknowledge that the University may still disclose my personal information where excepted by FERPA.

 Student’s Signature

_________

Date

_____

Registrar’s Concurrence

(for FERPA restrictions only) ___________________________________________________

Date _______________________

TO REVOKE A PREVIOUSLY IMPOSED RESTRICTION ON THE DISCLOSURE OF INFORMATION

I hereby request that the University cancel and release the restriction I had previously placed on the disclosure of (select one) □ my

directory □ all my information. I understand that by canceling this restriction, directory information may be released at the Univer-

sity’s discretion and without my prior consent. As required, I have attached a copy of my official identification.

 Student’s Signature

__________

Date

_____

OFFICE USE ONLY

Data entry

Rev 11/09

Ferpa Records Restriction Form

Related Articles

Related forms

Related Categories