Data Privacy Violation Complaint Form

Printable Form
Data Privacy Violation Complaint Form.pdf


Data Privacy Violation Complaint Form 

 
Parents, eligible students (students who are at least 18 years), principals, teachers, and other employees of the Waterford-Halfmoon Union Free School District may file a complaint about a possible breach or improper disclosure of student data and/or protected teacher, principal, or district staff data. 
 
Contact Information: First Name:  _________________ Last Name: __________________ 
 
Phone Number:  ______________ Email:  _____________________ 
 
Role/Relationship to Student (if applicable):  ________________________ 
 
Building Affiliation:  ____________________________________________ 
 
 
Possible Improper  Disclosure or Breach Information: Description of Event:  ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 
 
Description of Possible Disclosed Data: ____________________________ ____________________________________________________________ 
 
Description of How Complainant Learned of Possible Disclosure: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ 
 
**Attach additional sheet with further information if necessary 
Please Return Completed Form to: Data Privacy Officer Waterford-Halfmoon Union Free School District 125 Middletown Road Waterford, New York 12188