Record of Disclosures

The following form is a Record of Disclosures to be maintained in compliance with the Family Educational Rights and Privacy act of 1974.

This form must be completed whenever a student record is disclosed to someone other than the student, except for disclosures (1) of directory information, or (2) disclosures to an NC State University official with a legitimate need to know, or (3) disclosures made with the written consent of the student.

FILE ___________________________(Student’s Name & ID Number)

Office___________________________(Registrar, Dean, etc.)

NAME OF PERSON REQUESTING INFORMATION_________________

TITLE_________________

ORGANIZATION REPRESENTED________________________________

INFORMATION DISCLOSED____________________________________

Note: REQUESTING PARTY MUST BE NOTIFIED NOT TO RELEASE THE INFORMATION TO ANYONE ELSE UNLESS PERMISSIBLE UNDER FERPA. WAS SUCH NOTICE GIVEN IN THIS CASE:

Yes _______ No _______

DISCLOSED BY: ____________________________________(signature & printed name)

Date of disclosure ____________________