Office of Registration & Record
Phone: (812) 237-2020 Fax: (812) 237-8039
Un
er t
e Fe
era
Fami
y E
ucationa
Rig
ts an
Privacy Act o
1974, as amen
e
Decem
er 31, 1974, universities wi
o
er a stu
ent t
e opportunity o
esignating Directory In
ormation as con
i
entia
recor
s.
The University, in accordance with the Act, has designated the following categories of information about you as public unless you choose to exercise your right to
have this information withheld.
Director
Information includes:
1. Full name
2. Address: campus and home
3. Telephone listing
4. E-mail address
5. Major fields of study, including teacher licensure, majors and minors
6. Participation in officially recognized activities and sports
7. Weight, height, and position of members of athletic teams
8. Dates of attendance (including current classification, matriculation, and withdrawal date)
9. Degrees, awards, honors, and dates received, including honor roll designation
10. The most recent previous educational institution attended
11. Full- or part-time status
12. Photograph, but limited to the student identification photograph
P
ease cons
er very care
u
y t
e consequences o
your
ec
s
on to request t
e Un
vers
ty not to re
ease t
s
D
rectory In
ormat
on.
Your request to
ave your D
rectory In
ormat
on
es
gnate
as con
ent
a
w
e
n e
ect FOREVER unt
resc
n
e
y you
n wr
t
ng,
regar
ess o
w
t
rawa
or gra
uat
on. I
you
es
gnate your D
rectory In
ormat
on as con
ent
a
t
en NO INFORMATION OF ANY
KIND MAY BE RELEASED, even to you, w
t
out your wr
tten consent!
Exam
les
> The University could not release your telephone number to family in the event of an emergency.
> The University could not release information to a prospective employer.
> Responses to inquiries for any student who has designated his/her information as confidential must be "I have no information about this person."
Please select one of the followin
:
I wish to have my Directory Information designated as confidential. I am verifying that I am enrolled and that I understand that if I have to be readmitted
for any reason, I must submit a new student directory information confidentiality form.
I wish to remove the confidential designation of my Directory Information.
By signing below, you are indicating that you wish to have your Directory Information designated OR removed as confidential. Please forward the signed form and
a copy of your driver's license to: The Office of Registration and Records, Parsons Hall, Room 009, Terre Haute, IN 47809.
(Print) Last Name First Name University ID # (XXX-XXX-XXX)
Student Signature Date
Revised 02/21/2018 Index As: Confidentiality Request
Desi
nation of Student Directory Information as a Confidential Record
