Fillable Fresno State University - Form 405 Authorization/Request for Access to Student Records

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Fresno State University - Form 405 Authorization/Request for Access to Student Records

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The Fresno State University - Form 405 Authorization/Request for Access to Student Records form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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Enclosure 1
AUTHORIZATION/REQUEST FOR ACCESS TO STUDENT RECORDS
Student Name Student I.D. Number
Student Status: Current
Phone Former
Record Requested
Purpose(s) of Disclosure
Person to whom access is granted (if other than student)
Date Student's Signature
Medical or psychological records relating to treatment received at Student Health and
Psychological Services may not be reviewed directly by the student. Instead, a medical doctor or
other appropriate professional must be authorized to conduct that review.
Information placed in a student's Professional Placement File prior to January 1, 1975, with an
understanding, expressed or implied, that it was not to be made available to or seen by the
student concerned, may not be reviewed directly by the student.
NOTE: This form is to be used unless a similar authorization is personally developed and
submitted by student.
Enclosure 2
- 405 -
ACCESS
LIST
A record of requests for, or disclosures of, information must be maintained in instances except
when:
(a) the request is made by the student for his/her own use;
(b) disclosures are made in response to a written request from the student; (The
written request will be placed in the record.)
(c) the request is made by a school official; or
(d) the information sought is in the category of Directory Information.
The Access List in the case of , is:
(Last Name) (First Name)
Date Party Requesting Address
Reason for Request
Party Releasing Office
Date Party Requesting Address
Reason for Request
Party Releasing Office
- 405 -
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Fresno State University - Form 405 AuthorizationRequest for Access to Student Records

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Completed 30 May 2020

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