Danville Area Community College
Procedures for Compliance with the Illinois Student Optional Disclosure
of Private Mental Health Information Act
In accordance with Board Policy 3023.0 and the Illinois Student Optional Disclosure of Private Mental
Health Act (Public Act 99-278), a student’s mental health information is considered private in nature
and will not be released to a third party without that student’s prior written consent, unless otherwise
provided by other state or federal laws.
A student who desires to authorize disclosure of certain private mental health information about
himself or herself to a designated person for purposes set out in the Act must complete a Student
Optional Disclosure of Private Mental Health Information form, which shall be made available on links
included on the College’s Admissions webpage and the Current Students webpage. This form must be
submitted to the Director of Admissions & Records/Registrar in the Admissions & Records Office
(Vermilion Hall). The form will remain valid until the student revokes his or her authorization by
notifying the College in writing that he or she is withdrawing this authorization.
In the event that a qualified examiner, who is employed by the College in that capacity, determines
that a student poses a clear danger to the student or others, the qualified examiner will immediately
contact the Director of Admissions & Records/Registrar or her designee to determine if that student
has completed and provided the College with a Student Optional Disclosure of Private Mental Health
Information form designating a person to whom the College is authorized to disclose this information.
If the student has filed a Student Optional Disclosure of Private Mental Health Information form, the
qualified examiner will, as soon as possible, but no more than 24 hours after making the determination
described above, attempt to contact and notify the designated person that the qualified examiner has
made a determination that the student poses a clear, imminent danger to themselves, or others. The
College shall document any and all attempts of the qualified examiner to reach the designated person.
Danville Area Community College does not typically employ individuals who have the credentials to
serve as “qualified examiners” within the meaning of the Act, who are in a position to make the mental
health determination described above. Nor is the College required to employ such individuals.
Therefore, the College cannot assure a student that it will be able to disclose the student’s condition to
the person that the student has designated to receive confidential mental health information about
him or her in the circumstances provided for in the Act.
The Dean of Student Services will periodically review whether the College employs a “qualified
examiner” who is in a position to make the determinations provided for in the Act.
Finally, consistent with the Family Educational Rights and Privacy Act (FERPA), the College may, in
situations where a health or safety emergency exists, disclose confidential personally identifiable
information about a student without his or her consent, to any individuals the College reasonably
determines to be in need of that information for public health and safety reasons, subject to the
conditions and limitations set out in FERPA.
Danville Area Community College
Student Optional Disclosure of Private Mental Health Information Form
The Illinois Student Optional Disclosure of Private Mental Health Act (Public Act 99-278) requires that
institutions of higher education provide to all students the opportunity to authorize the College in writing to
disclose certain private mental health information to a person designated by that student.
Who can I identify as a designated person?
A student may designate a parent, guardian, or other person over the age of 18 to receive certain private mental
health information from the College.
What information will be disclosed and under what circumstances?
The College may disclose a student’s mental health information to the designated person if a qualified examiner,
who is employed by the College, determines that the student poses a clear danger to himself, herself, or others.
The purpose of the disclosure in such a case is to protect the student or other person against a clear, imminent
risk that the student may inflect serious physical or mental injury, disease or death on himself, herself, or
another individual. The qualified examiner is required to disclose this information to the designated person as
soon as possible, but no more than 24 hours after making the determination that the student poses such a
danger.
Please note that the College does not currently employ any individuals who serve as qualified examiners and
who are in a position to make the mental health determination described above. Therefore, the College cannot
assure that by identifying a designated person, the College will be able to disclose the student’s condition to that
designated person.
STUDENT AUTHORIZATION
_____ YES, I authorize disclosure of my mental health information as described above to the individual I have
identified on this form, which shall be valid unless and until I revoke it by notifying the College in writing that I
am withdrawing this authorization.
_____ NO, I do not authorize the College to disclose my private mental health information as described above to
a designated person. If I change my mind, I understand I must submit a new form designating such an individual
and authorizing the College to disclose my mental health information to that individual under the circumstances
described above. I also understand that under certain circumstances as allowed and/or required by the law,
College officials may contact my parents, family members or others in the event of an emergency without my
consent.
Signature: Date:
_____________________________________________ ____________________________________
Student Information:
Name ___________________________________________________ Student ID ________________________
Date of Birth ____________________________ Phone Number _____________________________________
Address __________________________________________________________________________________
Designated Individual Contact Information:
Name ____________________________________________ Relationship to Student _____________________
Address ___________________________________________________________________________________
Contact Numbers: Cell Phone ______________________________ Home Phone _______________________
Work Phone ____________________________________________
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