To be used when a parent/guardian is requesting their child’s covered information under the Student Online Personal Protection Act. A parent/guardian is limited to two requests per child per fiscal quarter. If the covered information requested includes data on more than one student, the parent/guardian may inspect and review only the covered information relevant to his/her child.

Parent/Guardian Name:                     Phone Number:             

Address:                         Email:                     

Student Name:                         School:                    

I request an (choose one): ☐ Electronic Copy ☐ Paper Copy of my child’s covered information from the following operator(s):                                    

Parent/Guardian Signature    Date

Completed by the Records Custodian or Privacy Officer.

Request received on:                  

Covered Information due to parent/guardian on:                  

Operator contacted on:                  

Covered information received from operator on:                 

Covered information provided to parent/guardian on:             

Check, if applicable:

☐    Paper copy was provided instead of electronic copy because the District does not maintain the information in an electronic format and reproducing the information in an electronic format would be unduly burdensome to the District. 23 Ill.Admin.Code §380.20(a).

Record Custodian or Privacy Officer Signature    Date

ADOPTED:    December 16, 2021