Restraint of Release of Student Information Form
The Family Educational Rights and Privacy Act of 1974 (FERPA) is a federal law that protects the privacy of student education records. FERPA defines public/directory information which may generally be released and then limits the release of private, confidential information without the student’s signed consent. By completing and submitting this Restraint of Release of Student Information Form, you are verifying that you have read and understand IUPUI's policy on Access, Confidentiality and Disclosure of Student Records available at http://registrar.iupui.edu/confiden.html.
Public information at IUPUI is limited to:
Name University E-mail Address Major Field of Study Dates of Attendance Admission or Enrollment Status	Campus School or Division Class Standing Degrees and Awards Activities Sports and Athletic Information
Note: While FERPA regulations and the IU Release of Student Information Policy allow for the disclosure of address and phone as public information, at IUPUI address and phone information is NOT considered to be public and is not released to third parties. Since address and phone are not released, it would be rare that students would want to restrict the remaining IUPUI public information. However, for students who wish to add an extra layer of privacy, the following form is provided.
Name _________________________   Ten Digit Student Identification Number ___________________
* If Ten Digit Student Identification Number unknown, last 4-digits of SSN _____________________
I request that the IUPUI Office of the Registrar restrict the following public information:
______________ Home Address Only ______________ Local Address Only ______________ All Addresses	______________ Home Telephone Only ______________ Local Telephone Only ______________ All Telephone
______________ All Public Information Listed Above* *NOTE: To restrict all public information defined above, a student must come to the Office of the Registrar with picture ID. A total restraint of directory information cannot be accepted via the mail and needs to be thoroughly discussed with a supervisor at the Office of the Registrar.
I Understand:
This restriction is applicable until such time as I request in writing that it be removed That I must initiate this option by filing a Removal of the Restraint of Student Information Form, and That a copy of this restraint will be forwarded to my school or division and to other university offices that maintain student records
Student Signature _____________________________________________ Date_________________
School/Division _______________________________________________
Based on Indiana Policy on Student Records as amended and approved by the University Faculty Council (March 29, 1997), in compliance with Section 438 of "General Education Provisions Act" (as amended) entitled "Family Educational Rights and Privacy Act."