WVDE Privacy Management and Incident ResponseQuestions? Call the Office of Legal Services & Accountability:

304-558-7881

West Virginia Student Data Privacy

Parent/Guardian and Eligible Student Concern Form

The West Virginia Department of Education (WVDE) takes very seriously its responsibilities to protect students’ sensitive information. If you believe that your child’s (or your own) education records have been released improperly or in a way that is not consistent with federal, state, or local laws and policies, please use this form to report your concerns to the WVDE Office of Legal Services and Accountability.

Your Information
Last Name: / First Name: / Middle Initial:
Address: / City/State: / Zip Code:
Primary Phone Number: / Alternate Phone Number: / Best Hours to Call:
Email Address: / Best Method of Reaching You (select one):
☐ / Phone (at the times above) / ☐ / Email
What best describes your relationship to the student?
☐ / Parent or legal guardian
☐ / Self. I am an eligible student. (Provide your date of birth.)
MM / DD / YYYY
☐ / Other (Explain your relationship.)
Student Information
Student Last Name: / Student First Name: / Student Middle Initial:
Student Date of Birth: / Current Grade Level: / Current School:
MM / DD / YYYY
School and District Information
School (at which the incident happened): / County:
Principal: / Superintendent:
Dates of Attendance:
to / ☐ / Present / or
MM / DD / YYYY / MM / DD / YYYY
Information about the Release of Student Records
Please provide with as much information as possible about your claim that your child’s (or your own) student records or data were inappropriately disclosed. The more information we have, the more quickly we will be able to look into the incident and work toward an appropriate resolution.
What information was disclosed?
Is the information part of your child’s (or your own) official records? / ☐ / Yes / ☐ / No / ☐ / I don’t know
When did the disclosure happen?
(Please give a specific date, if possible.) / When did you find out about the disclosure?
(Please give a specific date.)
How did the disclosure happen?
☐ / Studentdata/records were shared without permission. / ☐ / An email with student data was shared improperly.
☐ / An unauthorized person accessed a computer system. / ☐ / Student data/records were posted online.
☐ / A computer with student data/records was stolen. / ☐ / Student data/records were posted in paper form.
☐ / Data/records (electronic or paper) were lost or stolen. / ☐ / Student data/records were improperly discarded.
☐ / Student data/records were improperly stored. / ☐ / Other(describe below in the “other details” section)
Was the incident an accident or done on purpose? / ☐ / Accidental / ☐ / Intentional / ☐ / I don’t know
If an individual disclosed the information, please provide as much information as you know about the person.
Name: / Title:
Role/Job Function: (if no/unknown title)
Other Relevant Details:
If you know who the information was disclosed to, please list as much information as possible about that person or group(including names, roles, and/or relationship to your child [or you], if applicable).
Please give other details or circumstances about the incident of which you are aware. (Describe “Other” disclosures here.)
How did you find out about the incident?
Have you communicated with anyone at the school or district about this incident? / ☐ / Yes / ☐ / No
If yes, please summarize those conversations and their outcomes. Attach copies of any emails or letters (if possible).
How has this incident affected your child (or you) to date?
To the best of your knowledge, what steps or actions, if any, have been taken to repair or correct this issue?
Review and Referral
After reviewing your claim, the WVDE Office of Legal Services and Accountability may need to discuss the issue with school and/or district officials and staff, other personnel within the WVDE, representatives of the U.S. Department of Education Family Policy Compliance Office, or others with a need to know.
Do you agree to allow WVDE staff to share information about your claim with other individuals and/or agencies that may need to know? (Please select one response below.)
☐ / Yes, I agree to allow information about this claim to be shared with other individuals or agencies.
☐ / No, I do not agree to allow information about this claim to be shared with other individuals or agencies.
Your Signature
By signing this form, I certify that the information is true and accurate to the best of my information, knowledge, and belief.
Signature / Date
Notices
Email this completed form to may also fax or mail the form to the WVDE Office of Legal Services and Accountability(see the instructions document for more details). A staff member from that office will respond to confirm that the department has received the information and will review your concerns.
Please keep a copy of this form and any supporting documents for your records.
The West Virginia Board of Education and the West Virginia Department of Education do not discriminate
on the basis of sex, race, color, religion, disability, age and national origin in employment and
in administration of any of their education programs and activities.

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