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New York State Education Department Identity …

New York State Education Department Identity Verification and Authorization to Access or Disclose Confidential Education Information Regarding Pre-School,

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Text of New York State Education Department Identity …

New York State Education Department Identity Verification and Authorization to Access or Disclose Confidential Education Information Regarding Pre-School, Elementary, Secondary, and Post-Secondary Education Instructions The purpose of this Identity Verification and Authorization is to establish the identity and authorization of an individual who seeks access to confidential education information, or who requests disclosure/release of such confidential education information. Such a request for access, disclosure or release most commonly will be submitted to the New York State Education Department ( Department ) through the Family Educational Rights and Privacy Act of 1974 ( FERPA ), the New York State Freedom of Information Law ( FOIL ) or the New York State Personal Privacy Protection Law ( PPPL ), and the Education Law 2-d. FERPA is a federal law that establishes the rights of students and parents with regard to access and disclosure of education records, and ensures privacy and confidentiality with respect to those records. Likewise, the Individuals with Disabilities Education Act ( IDEA ) is a federal law governing educational services to children with disabilities, which also emphasizes rights of privacy and confidentiality with respect to many special education records (34 CFR ). FOIL provides a presumption of public access to records held by State and local government entities, but provides protection from access to certain confidential information unless a person is specifically authorized to receive such information. Similarly, PPPL allows a person to request personal information that has been collected by an agency and pertains to that person (Public Officers Law 95). Education Law 2-d(g) also allows for parents to inspect and review specific educational records for their child. This form is provided as a means for eligible students, parents, guardians and other persons in a parental relationship to establish their identity and relation to the subject of the confidential records and to give the Department permission to release or disclose educational records. An eligible student is an individual seeking educational information about him/herself who has reached 18 years of age or attends a postsecondary institution (34 CFR ), or, if the student is currently receiving special education services, is over the age of 18 and the parent/guardian s rights under IDEA have been transferred to the student. FERPA requires the Department to use reasonable methods to identify and authenticate the identity of those seeking personally identifiable information from education records (34 CFR [c]). FOIL and PPPL also require a person who seeks access to confidential records pertaining to him/herself to present reasonable proof of identity or consents in writing to the disclosure of such record (Public Officers Law 89[2][c]). Pursuant to your inquiry about, or request to disclose, protected education records, you are being asked to provide the following information to the Department to confirm your identity and establish your eligibility to receive or direct disclosure of such records. This form must be completed and notarized in order for the Department to comply with any request or inquiry for the disclosure of protected educational record(s), information or data. Page 1 of 2 Identity Verification and Authorization I, ________________________________________ ____________, (print name) hereby affirm that I am the eligible student or a person in parental relationship to or a legal guardian of the student [check appropriate box], ________________________________________ ____________, (print name) to whom the confidential educational record(s), information or data relate. I affirm that I know of no reason for which I am lawfully prevented from receiving or authorizing release of the requested confidential educational record(s), information or data. My mailing address is: ________________________________________ _______________________________ ________________________________________ ________________________________________ __________ ________________________________________ ________________________________________ __________ My daytime telephone number, with area code, is: ________________________________________ _________ I specifically authorize the Department to release the confidential educational record(s), information or data specified in my written request made pursuant to FOIL, FERPA, PPPL, Education Law 2-d, and/or otherwise under law (check applicable box): All requested educational record(s), information and/or data (including special education*, if any) Requested special education records, only (*may include, but not limited to: Individualized Education Program ( IEP ), psychological/physiological assessments, and therapies) Other, specify: ________________________________________ _______________________________ ________________________________________ ________________________________________ __________ ________________________________________ ________________________________________ __________ ________________________________________ ________________________________________ __________ Note: this authorization applies to only records possessed or maintained by the Department I hereby give the Department permission to provide personally identifiable educational record(s), information or data to (check box): Myself (the person filling out this form) Third party (fill in name and contact information): ________________________________________ ___ ________________________________________ ________________________________________ __________ ________________________________________ ________________________________________ __________ ________________________________________ ________________________________________ __________ Note: This authorization shall remain in effect until it is revoked in writing. Do you authorize the Department to transmit protected educational record(s), information or data via email (check box): No Yes (Please provide email address): ________________________________________ ___________ Version: 7/2015 Page 2 of 2 Identity Verification and Authorization I understand the Department will rely on this document both for verification of identity and as authority to provide consent to release confidential educational record(s), information or data. Furthermore, I declare and affirm under penalty of perjury that the statements made herein are true and correct to the best of my knowledge, information and belief. ________________________________________ _______ ___________________________ Signature Date Acknowledgement To Be Completed by a Notary Public State of _________________________________ ) ) SS.: County of _______________________________ ) On the ______________day of _______________________ in the year ____________before me, the undersigned, personally appeared personally known to me or proved to me on the basis of satisfactory evidence to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument. ________________________________________ ______________ Notary Public (Please sign and affix stamp)

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