Authorization to Release Student Confidential Information

The Family Educational Right and Privacy Act of 1974 (FERPA), as amended, protects the privacy of educational records, establishes the rights of students to inspect and review their education records, and provides guidelines for the correction of inaccurate or misleading data through informal and formal hearings. This release applies to the disclosure of education records only. The student authorizing the release of his/her education records must sign this form before the Oklahoma State University Institute of Technology (OSUIT) Office of Academic Accommodations can release specified information. Third-party release is for informational purposes only.

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Full Name*

I (insert name), hereby authorize the OSUIT Office of Academic Accommodations to release information from my education records to:

Individual or Agency*

Address*

Relationship*

Phone Number*

The following education records are to be released to the person(s) and/ or agency (or agencies) named above. Check all that apply.

Record for Release*

All education records (this will include GPA, hours, grades, etc.)

Class schedule

Grades only

OtherPlease specify additional records if not the ones listed above.

Acknowledgment *

I acknowledge that this release applies to both verbal and written case information.

Important Note: This consent form is valid for one year after student’s last term of enrollment at OSUIT, unless student revokes it in a written request before that time. Student may revoke this consent at any time except to the extent that action already has been taken in reliance on it (e.g., information has been sent or received prior to the revocation).

If, during the course of service, student discloses that he or she is a victim of sexual assault, the OSUIT Office of Academic Accommodations is required by OSU policy to report the incident to the OSUIT Police, even if anonymously.

Student does not authorize further release to any other party. Student further understands that the OSUIT Office of Academic Accommodations and its staff, employees, coordinators, and directors cannot be responsible for confidentiality of information disclosed after said information has been released pursuant to this authorization, and student hereby releases the OSUIT Office of Academic Accommodations from any liability arising from such disclosure.

OSUIT ID*OSUIT ID Number (CWID)

Date*

Signature*Please type out your full name in place of signature.