Request for FERPA Information Disclosure Restriction
Student Name: ________________________________ Student ID#: _______________________
Directory Information is information that Durham Tech has determined may be shared about an
individual student which includes a student’s name, email address, current program of study, terms
enrolled, honors and awards, credentials earned, and participation in official student clubs or
organizations.
Directory Restriction
☐ I request the withholding of ALL directory information. This means that my information will not b
e
shared in any Durham Tech publications or press releases, including the Commencement Program.
F
ERPA Restriction
☐ I request the withholding of ALL (directory and non-directory) information. This means that my
attendance and existence at Durham Tech will not be acknowledged.
Revocation of Restriction
☐ I request that the college revokes the previously requested Directory Restriction or FERPA
Restriction, which is currently in place on my education record.
STUDENT AUTHORIZATION:
By signing below, I authorize Durham Technical Community College to place the restriction indicated
above, or revoke a previously requested restriction as indicated above, on my education record.
Student Signature: ____________________________________ Date: ____________________
Please return this form to the Student Information and Records office, Wynn Center (Building 10),
room 10-201 or fax it to 919-686-3768. Allow 3-5 business days for processing.
REVISED 9/2016
