Printable Form
Data Privacy Violation Complaint Form.pdf
Data Privacy Violation Complaint Form
Parents, eligible students (students who are at least 18 years), principals, teachers, and other employees of the Waterford-Halfmoon Union Free School District may file a complaint about a possible breach or improper disclosure of student data and/or protected teacher, principal, or district staff data.
Contact Information: First Name: _________________ Last Name: __________________
Phone Number: ______________ Email: _____________________
Role/Relationship to Student (if applicable): ________________________
Building Affiliation: ____________________________________________
Possible Improper Disclosure or Breach Information: Description of Event: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
Description of Possible Disclosed Data: ____________________________ ____________________________________________________________
Description of How Complainant Learned of Possible Disclosure: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________
**Attach additional sheet with further information if necessary
Please Return Completed Form to: Data Privacy Officer Waterford-Halfmoon Union Free School District 125 Middletown Road Waterford, New York 12188