Use this form to block the release of Directory Information
Instructions: By default, Directory (Public) Information may be released to the public for any student. The purpose of this form
is to allow a student exercise his or her right to block the release of Directory Information. Complete the form with all applicable
information and return it to the Registrars Ofce. Do NOT sign the form until you are in the presence of a staff member of the
Registrars Ofce, Financial Aid Ofce, or a Notary Public. A photo ID is required. Present the form to the Registrars Ofce,
TSC 246. This form may also be used to remove the privacy block on Directory Information.
(Student Name) (A-Number) (Birthdate)
(Student Signature) (Date)
If you are not completing this form in the presence of a Utah State University Registrars Ofce or Financial Aid Ofcial, this form
must be notarized. The original notarized form must be submitted to the Registrar’s Ofce in order to be valid.
Witnessed by Registrars Ofce or Financial Aid Ofce Ofcial:
Notary Signature: Date:
Last updated: 1/29/2009
Students at Utah State University are governed by the Family Educational Rights and Privacy Act (FERPA) and its regulations.
Under FERPA, Directory Information relating to the student is considered to be public information unless the student formally
requests in writing that it be kept condential. This form serves to process such requests.
Directory (Public) Information includes:
Name, User ID (A-Number), local and permanent address, electronic mail address, telephone number, date of birth, residency status,
degrees and awards received, most recent institution attended by the student, academic level, major eld of study, department or
college, enrollment status (undergraduate or graduate, full-time or part-time), participation in ofcially recognized activities/sports,
dates of attendance and graduation, weight/height of members of athletic teams, and photographs.
Block the Release of Directory Information. This option will prohibit Utah State University from releasing my directory
information except as specied under FERPA. The completion of this form will also prevent the Registrar’s Ofce from
releasing my own directory information to me unless I personally present valid identication at the Registrars Ofce.
Phone requests from me for directory information will not be accepted. Any future requests for such information from
persons or organizations unafliated with Utah State University will be refused. Specic questions regarding my records
must be resolved either in person with picture ID, or by mail/fax request with photocopy of a picture ID and my signature.
Utah State University cannot assume responsibility to contact me for subsequent permission to release this information.
Regardless of the effect upon me, Utah State University assumes no liability as a result of honoring my instructions that this
information be withheld. This restriction will remain in force until I complete a form to change this request.
Allow the Release of Directory Information (if previously blocked). This option will revoke any and all previous
declarations from me to block the release of my directory information. The revocation allows Utah State University to treat
my directory information as public information from this date forward and invalidates any previous instructions to the con-
Action to be taken (check one)
I hereby request that the Registrars Ofce take the above indicated action to either block or allow access to my Directory Information
as dened above. I have read and understand the consequences of the action requested above. This action will remain in force until I
complete a form to change this request.
Student Information