Request to Review Education Records

Name of Student:   _____________________________________________________________

Student Number:   _____________________________________________________________

Purpose of Review:   ___________________________________________________________

Item(s) of Information Requested: _________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Name of Requestor: ___________________________________________________________

Requestor’s Affiliation: _________________________________________________________

Office to Which Request Was Made: ______________________________________________

Names and Legitimate Interest of Any Additional Parties to Whom Records May Be Disclosed:

___________________________________________________________________________

___________________________________________________________________________

I hereby agree to keep the information disclosed to me confidential according to applicable legislation and regulations.

Signature ___________________________________________  Date:   __________________

……………………………………………………………………………………………….....

Disposition of Request:     __________ Approved      __________ Disapproved

Specify Materials Reviewed (Records, Types of Information):

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Signature of Official Approving Request __________________________   Date _____________

Name and Title of Official Supervising Review _____________________    Date _____________

When a request for student record information is received, this form must be completed and filed in the student’s file.  This form should not be completed when the request is

• from the student;

• accompanied by written consent from the student;

• for directory information;

• from a school official and a legitimate educational interest has been demonstrated; or

• a subpoena that by its terms requires non-disclosure to the student.

Source: 34 C.F.R. § 99.32

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