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Harpursville Unauthorized Disclosure Complaint Form

Student(s), Eligible Student(s), Parent(s), Teacher(s) or Principals and other Harpursville staff who have information indicating there has been a Breach or Unauthorized Disclosure of Protected Data may report that information to the Data Protection Officer, or DPO, by completing the form below.
COMPLAINT FORM
Important: Please answer all questions

Additional Information:
After submitting the form, the DPO will promptly acknowledge receipt of the report within 24 hours. When the factfinding process is complete, the DPO will provide the reporting party with the findings made at the conclusion of the factfinding process; this should occur no later than 60 days after the receipt of the initial report, and, if additional time is needed, the reporting party shall be given a written explanation within the 60 days that includes the approximate date when the findings will be available. 

Please note that the Harpursville DPO shall maintain a record of each report received of a possible Breach or Unauthorized Disclosure, the steps taken to investigate the report, and the findings resulting from the investigation in accordance with applicable record retention policies.
First Name
Last Name
Phone Number
Email Address
Role:
If "Other"
District
If Other:
Possible Improper Disclosure or Breach Information
Description of Events
Description of Possible Disclosed Data
Description of How Reporter Learned of Possible Disclosure
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