ORIGINAL-Student’s File COPY-Registrar’s FERPA File COPY-Institutional Research
Request For Non-Disclosure of Directory Information
These items listed on the reverse side of this form are designated as DIRECTORY INFORMATION by the Board of
Regents of Higher Education and may be released by the Northwestern Connecticut Community College (NCCC).
Und
er the provisions of the Family Educational Rights and Privacy Act of 1974, as Amended, you have the right to
withhold the disclosure of any or all of the “Directory Information” listed on the reverse side of this form. Please
consider very carefully the consequences of any decision by you to withhold Directory Information. Should you
decide to inform NCCC not to release any or all of this Directory Information, any future requests for such
information from non-institutional persons or organizations will be refused.
NC
CC will honor your request to withhold Directory Information but cannot assume responsibility to contact you for
subsequent permission to release them. Regardless of the effect upon you, the institution assumes no liability for
honoring your instructions that such information be withheld.
Considerations
1. Please give careful consideration to the consequences of withholding directory information. Should you do this,
any future requests for such information, including the fact that you are enrolled, from persons or organizations
unaffiliated with the university will be refused. This information will NOT be released even in emergency
situations. Our response when an inquiry is received about your student record will be, “We have no information
about this person.”
2. NCCC will not contact you when a request for information is made; therefore, if you do wish to have information
released to a specific person or organization while this request is in effect, you must establish a FERPA Consent to
Release for them. No information will be released to anyone, including you, without proof of identity.
3. NCCC will not print your name in graduation, honors and/or awards lists, including newspaper listings if
appropriate. Since nondisclosure stays on your record until you file a written request to remove it, please be
aware that this will prevent disclosure of your information to any and all prospective employers.
4. You must be a registered student during the term for which you are requesting nondisclosure of information.
If you do not want the information on the back of this form to be released, please complete this form and submit
it to the Registrar’s Office, Green Woods Hall Room 215. You must also show a Photo ID.
Student ID # @___________________
Student’s Name:______________________________________________________________
Student’s Address:____________________________________________________________
Student’s Signature:_______________________________________ Date:______________
PLEASE SUBMIT THIS FORM TO THE REGISTRARS OFFICE WITHIN THE FIRST TEN (10) DAYS
OF THE START OF THE SEMESTER.
FOR OFFICIAL USE ONLY:
Date Received:_______________ Date Entered Into Banner:_________________ By:__________________
ORIGINAL-Student’s File COPY-Registrar’s FERPA File COPY-Institutional Research
The Board of Regents for Higher Education has
designated the following as Directory
Information:
For purposes of access by school officials of the
Colleges and Universities governed by the Board
of Regents for Higher Education, the following is
designated as Directory Information:
Student name
Permanent mailing address
Month and day of birth
Photographs
Student identification number, User ID, or
other unique identifier
Email address
Telephone number
University or College previously attended or
currently attending
Dates of attendance
Full vs. part-time student status
Awards and honors
Class standing/year
Major, minor, concentration and/or program
of study
Degree(s)/Certificate(s) candidacy
Degree(s)/Certificate(s) earned
Previous Institutions attended
Graduation expected/completion dates
For purposes of access by military recruiters only,
the following is designated as Directory Information
(Student Recruiting Information):
Student’s name
Permanent mailing address
Telephone number
Age
Place of birth
Class standing/year
Major and/or program of study
Degrees received
Most recent educational institution attended
For purposes of participation in any
recognized activity or sports, the following
is designated as Directory Information:
Student’s name
City and State of Residence
Dates of attendance
Class standing/Year
Recognized activity or sport
Team performance statistics
Team position
Photos and videos
Awards
Height and weight of athlete
For purposes of disclosure to/access by the general
public, the following is designated as Directory
Information:
Student’s name
Permanent mailing address
Photographs
Dates of attendance
Major, minor, concentration and/or program
of study
Degree/Certificate candidacy
Degree(s)/Certificate(s) earned
Awards
Full vs. Part-time status
Anticipated graduation date
Graduation date
Connecticut Community College Only -
Student identification number, User ID, or
other unique identifier
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome