Family Educational Rights & Privacy Act; Minn. Government Data Practices Act, Minn. Stat.§ 13.32, subds. 3(I) and 8(a) and (b)
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Date/time of request: _______________________________________________________________________
To: _________________________________________________________________________________________ (Superintendent of school district or chief administrative officer of school)
From: ______________________________________ Student: ______________________________________
(Requester’s name/agency)
The basis for request:
_______ Juvenile delinquency investigation/prosecution
_______ Child protection assessment/investigation
_______ Investigation/filing of chips or delinquency petition
Response to request:
The school must provide the following information on request (mark all that apply) and a response provided: (yes/no)
_______ Student’s full name _______
_______ Home address _______
_______ Telephone number _______
_______ Date of birth _______
_______ Student’s school schedule _______
_______ Attendance record _______
_______ Photographs, if any; and _______
_______ Parent/caregiver names & addresses _______
_______ Telephone numbers _______
A record of the written request and the release must be maintained in the student’s file. Certification: the undersigned certifies that he or she is a member of the juvenile justice system. The juvenile justice system needs the requested data so it may effectively serve, before adjudication, the student whose records are released. The undersigned will not disclose the information received to any other party, except as provided under state law, without prior written consent as required by the Code of Federal Regulations, Title 34, Sect. 99.38(B). The undersigned further certifies that he or she understands that, by signing this request, he or she is subject to the penalties in Minn. Stat. § 13.09.
Signature/title ______________________________________________________________________________