WVDE Privacy Management and Incident Response
Questions? 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 Date of Birth:
MM
DD
Current Grade Level:
Student Middle Initial:
Current School:
YYYY
School and District Information
School (at which the incident happened):
County:
Principal:
Superintendent:
Dates of Attendance:
MM
DD
YYYY
to
☐ Present
or
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?
Parent/Eligible Student Concern Form
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☐ Yes
☐ No
☐ I don’t know
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WVDE Privacy Management and Incident Response
Questions? Call the Office of Legal Services & Accountability:
304-558-7881
When did you find out
about the disclosure?
When did the disclosure happen?
(Please give a specific date, if possible.)
(Please give a specific date.)
How did the disclosure happen?
☐
☐
☐
☐
☐
Student data/records were shared without permission.
An unauthorized person accessed a computer system.
A computer with student data/records was stolen.
Data/records (electronic or paper) were lost or stolen.
Student data/records were improperly stored.
Was the incident an accident or done on purpose?
☐
☐
☐
☐
☐
An email with student data was shared improperly.
Student data/records were posted online.
Student data/records were posted in paper form.
Student data/records were improperly discarded.
Other (describe below in the “other details” section)
☐ 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?
Parent/Eligible Student Concern Form
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WVDE Privacy Management and Incident Response
Questions? Call the Office of Legal Services & Accountability:
304-558-7881
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 ZoomWV@help.k12.wv.us. You 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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