REQUEST TO PREVENT THE DISCLOSURE OF DIRECTORY INFORMATION
Office of the University Registrar - Kent State University
"For your convenience: print, complete and return this form with required documentation."

DIRECTORY INFORMATION: The Family Educational Rights and Privacy Act (FERPA) is a federal regulation which governs how educational institutions collect and disseminate student records data. University policy 3342-5-09 defines the operational procedures and regulations that govern student record data at Kent State University, including the definition of "directory information", which is information which "may be disclosed on an unlimited basis by university personnel in response to oral or written requests." Directory Information at Kent State University includes the following information: Name, local and permanent address, email address, telephone number, dates of attendance, class standing (undergraduate/graduate; freshman, etc.), enrollment status (full/part time), major, degrees awarded, honors, awards, previous institutions attended, sports participation, and weight and height of athletes. Students may "restrict" the disclosure of directory information by completing this Request to Prevent the Disclosure of Directory Information form. Other student record information is not released to parties outside the university without the written consent of the student.

Please restrict the publication and release of Directory Information from my Kent State University educational record. I have indicated below, with an ‘X’, which categories of information I would like to restrict. By completing and returning this request to the Office of the University Registrar, PO Box 5190, Kent State University, Kent. OH 44242, or Room 108 Michael Schwartz Center,  the disclosure of this information to non-University parties will occur only with my written permission.

____ STUDENT DIRECTORY
* Restricts publication of your name and address in the student Phone Directory on Kent State University's web site. 


  • DEMOGRAPHIC INFORMATION
____ NAME *

*Note: If you restrict your name it will not appear in University publications, such as the Commencement Program, Dean’s List notification, etc.

____ ADDRESS FOR MAIL LIST *

* Note: Mail lists are not released to external agencies. This refers to non-academic or non-administrative mailings, such as those by student organizations.

____ PERMANENT ADDRESS

____ TELEPHONE NUMBER *
*Note: Will restrict all telephone numbers

____ EMAIL ADDRESS *
*
Note: Will restrict all email addresses

____ LOCAL ADDRESS


  • ACADEMIC INFORMATION
    *Note: Restriction of academic information prevents the release of information to anyone, including employers, health agencies, etc.
____ DATES OF ATTENDANCE ____ MAJOR ____ DEGREES AWARDED
____ HONORS ____ AWARDS ____ PREVIOUS INSTITUTIONS ATTENDED
____ ENROLLMENT  STATUS ____ CLASS STANDING

  • OTHER INFORMATION
____ ACTIVITIES / SPORTS
         PARTICIPATION
____ WEIGHT/HEIGHT OF ATHLETE 
____________________________________
(Print Student Name)
________________________________________
(Student Signature)
_______________________________
(Student ID Number)
_________________________
(Date)
_______________________________
(Daytime Phone – including area code)

Note: This restriction is effective immediately and will remain in effect until written notification to remove the restriction(s) is received from the student.

Distribution: Alumni Office, Sports Information, Student File    Clerk Initials:___________    Date:_________________


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Updated: 8/16/01