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FORM APPROVED: Complaint Form Instructions: The United States (U.S. Department of Education)

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Complaint Form
FORM APPROVED
OMB NO:
1880-0544
Exp:07/31/2022
UNITED STATES DEPARTMENT OF EDUCATION
FamilyEducational Rights and Privacy Act
Instructions: The United States Department of Education’s (Department) Student Privacy Policy Office
(SPPO) reviews, investigates, and processes complaints of alleged violations of the Family Educational Rights
and Privacy Act (FERPA); 20 U.S.C. 1232(g), (h) and 34 CFR part 99. FERPA is a Federal law which affords
parents certain rights with regard to their children’s education records. The term “education records” is defined
under FERPA, with certain exclusions, as those records that are directly related to a student and which are
maintained by an educational agency (e.g., a school district) or institution (e.g., a school or postsecondary
institution), or by a party acting for the agency or institution, to which funds have been made available under any
program administered by the Secretary of Education.
These rights include the right to inspect and review their children’s education records, the right to seek to have
their education records amended, the right to have some control over the disclosure of personally identifiable
information contained in their education records, and, the right to file a written complaint with SPPO regarding
an alleged violation of FERPA. Once a student reaches 18 years of age or begins attending a postsecondary
institution, he or she becomes an “eligible student,” and all of the parent’s rights under FERPA transfer to the
student.
SPPO investigates written complaints alleging a violation of FERPA by an educational agency or institution, a
state educational agency (SEA) (if alleging denial to inspect and review education records maintained by the
SEA), or a third party, if the complaint: 1) is filed by a parent or eligible student with FERPA rights over the
education records which are the subject of the complaint, or his or her attorney or advocate; 2) is submitted to
SPPO within 180 days of the date of the alleged violation or of the date that the complainant knew or reasonably
should have known of the alleged violation; and, 3) contains specific allegations of fact giving reasonable cause
to believe that a violation of FERPA has occurred.
Individuals who want to file a complaint should do so by completing this Complaint Form (available at https://
studentprivacy.ed.gov) in its entirety and submitting it electronically or by mail. If you choose to submit this
form electronically, please note that it is a fillable PDF (Portable Document Format) and works best when used
with Adobe Reader, available for free download at https://get.adobe.com/reader/. Once you have completed the
form, please type your name in the signature space and click “Submit Form.” Your computer’s default e-mail
software program should then open and create an e-mail with the Complaint Form attached. In order to complete
the submission process, you must send this email, and attachment, as appropriate.
In the event that you have either not selected a default e-mail software program on your computer, or the default
e-mail software program you have selected does not open when clicking “Submit Form,” in order to complete the
submission process, you must either save the form, manually attach it to an e-mail, and send that e-mail to
FERPA.Complaints@ed.gov; or, print the form, and sign and mail it to:
Student Privacy Policy Office
U.S. Department of Education
400 Maryland Avenue, SW
Washington, D.C. 20202-8520
1
You should receive a confirmation of SPPO’s receipt of your complaint within three business days from the
date of your submission. Failure to complete the Complaint Form in its entirety or to not provide any of the
information required for SPPO to determine whether your complaint contains specific allegations of fact
giving reasonable cause to believe that a violation of FERPA has occurred, may result in, among other things,
the dismissal or return of your complaint to you in order to obtain additional information needed by SPPO to
further consider your complaint. If your complaint is dismissed, you may choose to resubmit a new complaint
per the instructions set forth above and in accordance with the requirements of FERPA.
Also, you should be aware that when reviewing, investigating, or processing your complaint, SPPO may
disclose, without your prior, written consent and pursuant to routine uses of the records that have been
published in the system of records notice covering FERPA complaints, information contained in your
complaint, such as the name of the complainant, the name of the student if the student did not submit the
complaint, and the alleged violation(s), including, but not limited, to the educational agency or institution
against which your complaint has been made.
SECTIONS 1 & 2: STUDENT AND COMPLAINANT INFORMATION
To complete these sections, please provide all requested information, including the student's correct birthdate.
An attorney or advocate may file a complaint on behalf of a parent or an eligible student; however, SPPO will
not discuss the complaint with the attorney or advocate without the prior, written consent of the parent or
eligible student, as applicable. SPPO will dismiss anonymous complaints and complaints filed by a party other
than the parent or eligible student who maintains FERPA rights over the education records that are the subject
of the complaint, or his or her attorney or advocate. Please note that a parent of an eligible student does not
maintain rights over the education records of the eligible student and may not file a complaint alleging that his
or her rights as a parent under FERPA have been violated.
SECTION 3: EDUCATIONAL AGENCY OR INSTITUTION INFORMATION
This section requires that you provide, among other information, the name and address of the current
superintendent of the school district, the president of the college or university, the state educational agency
(SEA) official (if alleging denial to inspect and review education records maintained by the SEA), or the
appropriate official of a third party, that you are alleging violated FERPA. FERPA applies directly to
educational agencies and institutions that receive Federal funds under programs administered by the
Department. For instance, private elementary and secondary schools generally do not receive funds from the
Department and are, therefore, not generally subject to FERPA. SPPO generally will dismiss complaints filed
against elementary or secondary schools that are not listed on the Department’s National Center for Education
Statistics Public School website (available at https://nces.ed.gov/ccd/schoolsearch/). Please note that it is
extremely important that you enter the specific date (mm/dd/yyyy) of the alleged violation in this section for us
to accurately determine the timeliness of your complaint. As stated above, a complaint must be filed within
180 days of the alleged violation or within 180 days after the complainant knew or reasonably should have
known of the alleged violation.
SECTION 4: FERPA VIOLATION INFORMATION
In describing the alleged violations, you must respond to all of the information requested in the heading(s) that
pertain to the nature of your complaint. For instance, if you are alleging a violation based on denial of access to
your, or your child’s, education records, you must (1) list the education records you requested; (2) indicate that
the educational institution or agency maintains the requested education records and how the education records
are maintained (if known); (3) provide the date(s) and means by which you requested access; (4)
2
indicate the name and position of the official(s) to whom you made the request for access to the education
records; and (5) describe any response received to your request or any actions taken by the educational agency
or institution in response to your request. Your response should only include the relevant facts that would give
reasonable cause to believe that a violation of FERPA has occurred. To the greatest extent possible, please
limit your response to the space provided in this Complaint Form; if more space is needed, you may attach
additional documents in which you further describe your complaint. Failure to provide any of the required
information may result in, among other things, your complaint being dismissed or returned to you for
additional clarification, which would delay the processing, and might impact the timeliness, of your complaint.
SECTION 5: CORRESPONDENCE INFORMATION
If there is any correspondence or other information, such as newspaper articles, website postings, e-mail or
letter exchanges, that substantiates your allegations, please briefly describe it in this section. You may also
attach copies of relevant documents that support your allegations. Please note that SPPO will not accept the
submission of audio or video files, CD/DVDs, or thumb drives. Also, the submission of nonessential,
voluminous, or nonresponsive information may, among other things, delay the processing, or result in the
dismissal or return, of your complaint.
SECTION 6: CERTIFICATION
Certify that the information you have provided in the Complaint Form is true and correct under penalty of
perjury by typing in your name in the signature space, if filing electronically, or by printing out the Complaint
Form and signing it, if filing by mail.
3
UNITED STATES DEPARTMENT OF EDUCATION
Family Educational Rights and Privacy Act
Instructions: Complete the fields below for Sections 1-6. Periodically save the form to avoid losing information. If you make an error, click
the Reset Form button at the bottom of the page to reset form fields. Click the submit button at the bottom of the page to submit your form to
the Student Privacy Policy Office (SPPO) as previously described in the instructions section on Page 1.
SECTION 1: STUDENT INFORMATION
First Name Last Name Date of Birth
SECTION
2:
COMPLAINANT
INFORMATION
Your relationship
to
the student whose
education
records
are
the subject of
this
complaint.
(If an attorney
or
advocate,
please note that
SPPO
will not
discuss
the complaint with you
without the prior consent of
the parent
or
eligible student who
maintains
the
rights
under
FERPA
.)
Parent or Legal Guardian
Self
Other (ex. Attorney/advocate on behalf of the parent or eligible student)
First Name Last Name
Street Address Phone Number
Email
City
State Zip
Check
if
SPPO may
use
this
email
address
to
contact
you.
SECTION 3: EDUCATIONAL AGENCY OR INSTITUTION INFORMATION
Name and title of the school district superintendent, the president of the college/university, or state educational agency (SEA) official
(if alleging denial to inspect and review education records maintained by the SEA) or the appropriate official of a third party.
Name
of
educational
agency
and
school official
you
contacted
in an
attempt to resolve this matter
Phone Number
Mailing Ad
dress Dates Attended
City State
Zip
Date of Alleged Violation
Name and title of school official
(ex. s
chool d
istrict superintendent, t
he president o
f the college/university, o
r state educational agency (SEA) official (if alleging denial to inspect and
review education records maintained by the SEA) or the appropriate official of a third party)
ED-EMVC.002.0Exp. (02/28/2021)
ED 162; SORN Citation 64 30107 (18-05-02)
Page 1 of 4
SECTION 4: FERPA VIOLATION INFORMATION
What is the nature of the alleged FERPA violation? Please provide clear, succinct responses addressing all of the information
requested in the heading(s) that pertain to your complaint.
If
you
have
been
denied
access
to
your,
or
your
child’s,
education
record(s):
(1)
list
the
education
record(s)
you
requested
from
the
educational
agency
or
institution;
(2)
indicate
whether
the
educational
agency
or
institution
maintains
the
requested
education
record(s)
and,
if
so,
how
the
education
record(s)
is
maintained
(if
known)
and
the
period
of
time
such
record(s)
is
retained
(if
known);
(3)
provide
the
date(s)
and
means
by
which
you
requested
access
to
the
education
record(s);
(4)
indicate
the
name
and
position
of
the
official(s)
to
whom
you
made
the
request
for
access
to
the
education
record(s);
and,
(5)
describe
any
response
that
you
received
to
your
request
or
any
action(s)
taken
by
the
educational
agency
or
institution
in
response
to
your
request.
If
you
have
been
denied
the
opportunity
to
amend
your,
or
your
child’s
education
record(s):
(1)
describe
the
education
record(s)
you
sought
to
amend;
(2)
the
information
in
the
education
record(s)
that
you
wanted
amended
and
the
specific
correction
that
you
requested
to
such
information;
(3)
the
reason
you
believe
that
the
information
in
the
education
record(s)
is
misleading,
inaccurately
recorded,
or
an
invasion
of
your,
or
your
child’s
right
to
privacy;
(4)
the
date
you
requested
to
amend
the
education
record(s);
(5)
the
name
and
title
of
the
school
official
to
whom
you
made
the
request
to
amend
your,
or
your
child’s
education
record(s);
(6)
any
response
that
you
received
to
your
request
or
any
action(s)
taken
by
the
educational
agency
or
institution
in
response
to
your
request;
and,
(7)
the
result
of
any
hearing
held
by
the
educational
agency
or
institution
on
the
matter.
ED-EMVC.002.0Exp. (02/28/2021)
ED 162; SORN Citation 64 30107 (18-05-02)
Page 2 of 4
If your, or your child’s, education record(s) or personally identifiable information contained in such education record(s) was improperly
disclosed without your prior, written consent, indicate specifically: (1) what education record(s) and/or personally identifiable
information was disclosed and the date of such disclosure (if known); (2) whether the information disclosed was recorded in the student's
education records; (3) the name and title, or job function, of the school official who made the disclosure; (4) the individual to whom the
disclosure was made and relationship, if any, to the educational agency or institution, and to the student; (5) the circumstances under
which the disclosure was made; (6) how and when (date) you became aware of the disclosure; and, (7) a description of any
communication between you and the disclosing individual or entity, as applicable, regarding the disclosure.
SECTION 5: CORRESPONDENCE INFORMATION
Describe any correspondence, such as newspaper articles, website postings, e-mail or letter exchanges, that substantiates the information
specifically required in Section 4 above. You may also attach copies of those relevant documents that support your allegations. Please note
that we will not accept the submission of audio or video files, CD/DVDs, or thumb drives. Also, the submission of nonessential, voluminous, or
nonresponsive information may, among other things, delay the processing of your complaint, and could result in the dismissal and return of
your complaint.
ED-EM VC.002.0Exp. (02/28/2021)
ED 162; SORN Citation 64 30107 (18-05-02)
Page 3 of 4
SECTION 6: CERTIFICATION
I certify under penalty of perjury that the foregoing is true and correct.
Signature:
Date:
Privacy Act Statement. The Department is authorized to solicit the information contained in this Form by 20 U.S.C. 1232g, h. Your disclosure of the information requested on
this Form is voluntary, but if you fail to provide any of the information, it may result in, among other things, your complaint being dismissed or returned to you for additional
clarification. The principal purpose for which the information requested on this Form will be used is to resolve your complaint and determine whether the educational agency or
institution violated FERPA. The Department has published the routine uses for which the information requested on this Form may be used in a system of records notice entitled
"Family Educational Rights and Privacy Act (FERPA) and the Protection of Pupil Rights Amendment (PPRA) Record Systems (18-05-02), which was last published in the
Federal Register on June 4, 1999 (64 Fed. Reg. 30106, 30123-24). The routine uses include, but are not limited to, disclosing records to the educational agency or institution
against which a complaint has been made or the State Educational Agency in that State. The Department may modify and update this system of records notice, in which case that
update in addition to the Department's other systems of records notices may be found at: https://www2.ed.gov/notices/ed-pia.html. The effects of not providing any of the
requested information on this Form may include, among other things, that your complaint is dismissed or returned to you for additional clarification.
Paperwork Burden Notice. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a
valid Office of Management and Budget (OMB) control number. The valid OMB control number for this information collection is 1880-0544. Public reporting burden for this
collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Obligation to respond is voluntary. If you have questions on your individual submission of this form,
write directly to: Student Privacy Policy Office, U.S. Department of Education, 400 Maryland Avenue, S.W., Washington, D.C. 20202-8520.
Reset Form
Print Form
Submit Form
ED-EMVC.002.0Exp. (02/28/2021)
ED 162; SORN Citation 64 30107 (18-05-02)
Page 4 of 4
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FORM APPROVED: Complaint Form Instructions: The United States (U.S. Department of Education)

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Completed 8 April 2022

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