Revised 3/24/2020
The Family Education Rights and Privacy Act of 1974 (FERPA) designates certain information contained in a student's
record as “directory information”, and grants the University the right to disclose “directory information” to
anyone, without consent from the student.
The following data elements are defined as “directory information” at Southern Connecticut State University:
name, mailing address, permanent telephone number, gender, dates of enrollment (including full or part
time status), major field of study, date of graduation, honors, degrees and awards received, previous field of
study, previous school attended, photo I.D., and participation in officially recognized activities and intercollegiate
sports, including for members of athletic teams, age, class status, weight, height, high school and hometown.
Southern Connecticut State University is committed to the protection of the privacy of student records. Please
complete and submit this form to request your directory information to be withheld from disclosure, except
when required by law.
Student Information
Student ID #: _______________________________
Last Name: _________________________________
First Name: ________________________________
Middle Initial: ________
Maiden/Other names used while attending SCSU: _______________________________________________
Date of Birth: __________________
Please select one from the following:
Currently Enrolled Previously Enrolled, dates of attendance ___________________________
Directory Information Non-Disclosure Form
Registrar’s Office
501 Crescent Street
New Haven, CT 06515-1355
Phone: 203-392-5301
Fax: 203-392-7144
Email: Registrar@SouthernCT.edu
Web: OneStop.SouthernCT.edu
Primary Phone Number: ___________________________________
Street Address: ___________________________________________________________________________
City: _________________________________ State: _________________ Zip Code: __________________
I understand that this Withhold Request prohibits the University from verifying enrollment or degree status, and remains in
continuous effect until such time as I notify the Registrar’s Office in writing that I wish to revoke the hold.
____________________
__________________________________________________________________
Student Signature
Date
Note: Students may create a digital ID using their SCSU email by clicking the
signature block above, or the form may be accepted
as an attachment from their SCSU email without a signature.
click to sign
signature
click to edit