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Appendix B-fillable (University of Dayton)

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1
APPENDIX B to Policy on Disclosure of
Education Records: RECORDS REQUEST FORM
(This form is for use by non-students who seek access to education records.)
To obtain educational records from a FERPA Gatekeeper, fill out items 1-9 of this form and
give to the appropriate gatekeeper listed on Appendix A. If your request is approved, you
may then be asked for additional information.
1. Name of requestor: _______________________________________________________
2. Department: ____________________________________________________________
3. Contact Information (phone, email, campus +4): _______________________________
________________________________________________________________________
4. Records requested (describe): ______________________________________________
________________________________________________________________________
________________________________________________________________________
5. Purpose for seeking records: _______________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
6. Have you considered seeking student consent? (explain) _______________________
________________________________________________________________________
________________________________________________________________________
7. Requestor’s Signature: ____________________________________________________
(Date)
8. Signature of Vice President or Dean: _________________________________________
(Date)
9. Gatekeeper to whom request submitted: _____________________________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name of gatekeeper handling request: ____________________________________
Request is: □ Approved
□ Denied
□ Approved with modification
Explanation of action: ________________________________________________________
___________________________________________________________________________
Gatekeeper signature: _______________________________________________________
(Date)
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Completed 21 July 2020

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