Fillable Access To Student Records Form (University of Mississippi Medical Center)

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Access To Student Records Form (University of Mississippi Medical Center)

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The Access To Student Records Form (University of Mississippi Medical Center) form is 4 pages long and contains:

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  • 13 other fields

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File type: PDF

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The University of Mississippi Medical Center School of Medicine
-Medical Education-
Faculty/Staff Access to Student Educational Records Form
Instructions
This form is designed to outline faculty (or staff) need/rationale for access to student educational
records.
Please take a moment to review the form and any prior comments before filling out your particular
section. Fill out each section completely. Areas such as date of referral and comments have been
designated as mandatory and must be filled out before you will be able to send this form to other
designated users.
When sending this form to additional faculty, please keep in mind that this is confidential
information, bound by the regulations set forth by FERPA and/or HIPPA.
Faculty/Staff Access to Student
Educational Records Form
The University of Mississippi Medical Center School of Medicine
-Medical Education-
Faculty/Staff Access to Student Educational Records Form
Name of faculty/staff requesting access Date of Request
Reason for the request.
Reason that the requester’s job requires access to student data.
Specific information needed to be accessed.
By providing your initials, you are attesting to the accuracy and completeness of the information provided in
this form.
I have a legitimate educational interest for the data access request.
I am responsible for exercising due care to protect this information from unauthorized
disclosure.
I understand that unauthorized access and use/dissemination of data are serious
offenses which may be subject to discipline.
Signature of faculty or staff
Submit
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signature
click to edit
For Office Use ONLY:
Date form received by the Office of the Registrar
Date form sent to the Office of Medical Education
Signature of the reviewer Date
Mark “x” for decision.
Access Granted
Access Denied
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signature
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Access To Student Records Form (University of Mississippi Medical Center)

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Completed 25 July 2020

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