WVDE Privacy Management and Incident Response
Questions? Call the Office of Legal Services & Accountability:
304-558-7881
West Virginia Student Data Privacy
Citizen Concern Form
The West Virginia Department of Education (WVDE) takes very seriously its responsibilities to protect students’ sensitive
information. If you believe that any student’s 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 role?
☐ Citizen
☐ Parent/guardian of a studenta
☐ Other relative of a student
☐ Studenta
☐ Educator or other school staffb
☐ Other:
a. If you are a parent or guardian who would like to report a privacy incident involving your own child, or if you are a student who
would like to report an incident involving your information, please use the “Parent/Guardian and Eligible Student Concern Form.” If
you are reporting a privacy incident in which other students (not your child or yourself) are involved, please use this form.
b. If you are an educator or other school staff member and you have a reasonable expectation of a need for protection from
retribution or retaliation, please contact your district superintendent or designee pursuant to Policy 4373, Chapter 5, Section 3.
Information about the School and Students Affected
School (at which the incident happened):
County:
Principal:
Superintendent:
How many students were affected by the release of information?
If you are unsure of an exact number, give your best estimate.
If you know the name(s) of the student(s) whose records were disclosed, please list first and last name(s) and grade level.
Information about the Release of Student Records
Please provide with as much information as possible about your claim that 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 that was disclosed part of students’ official records?
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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 students, 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 the students (or families) whose records were disclosed?
To the best of your knowledge, what steps or actions, if any, have been taken to repair or correct this issue?
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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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