Churchville-Chili

Central School District

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Improper Data Disclosure Reporting Form

Improper Data Disclosure Reporting Form
The Churchville-Chili Central School District takes security of student data seriously. If you believe there has been a possible breach or improper disclosure of student data, please complete this form and submit it online or print out the form and mail it to the district Data Privacy Officer. Churchville-Chili Central School District, 139 Fairbanks Road, Chruchville, NY 14428.

Full Name of Reporter:

Phone Number of Reporter:

Email Address of Reporter:

Role of the Reporter:

Parent
Student
Teacher
Staff
Administrator

Date the violation occurred:

Name(s) of person involved

Description of data compromised:

Description of the improper disclosure or data breach:

Any additional information relevant to the incident:

I certify that the information I have provided is true to the best of my knowledge.

Yes
No

To validate your submission, please answer the following math problem: