Springbrook Report an Improper Disclosure

Report an Improper Disclosure
Reporting a Complaint

All complaints should be submitted:
- Using this form: Springbrook Report an Improper Disclosure form; or
- In writing to:
  - Springbrook Schools Compliance Officer
    Rob Vogel, QA Director
    5588 State Highway 7
    Oneonta NY 13820
    607-353-7272; or
- Using the NYSED Unauthorized Disclosure Complaint Form
Response to Complaints

Upon receipt of a complaint, Springbrook Schools will promptly acknowledge receipt of the complaint, commence an investigation, and take the necessary precautions to protect personally identifiable information (PII).

Following the investigation of a submitted complaint, Springbrook Schools will provide the individual who filed the complaint with its findings. This will be completed within a reasonable period of time, but no more than 60 calendar days from the receipt of the complaint by Springbrook Schools.

If Springbrook Schools requires additional time, or where the response may compromise security or impede a law enforcement investigation, Springbrook Schools will provide the individual who filed the complaint with a written explanation that includes the approximate date when Springbrook Schools anticipates that it will respond to the complaint.
Complaint Details

Please do NOT include any information in this form that would constitute student or teacher or principal's personally identifiable information (PII). Springbrook Schools will contact you if additional information is needed.

Personally Identifiable Information (PII) is generally defined as any data from the student records of an educational agency that could potentially be used, alone or in combination with other data elements, to identify a particular student, or teacher or principal's annual professional performance review (APPR) data. For more information on FERPA (Family Educational Rights and Privacy Act), which is the federal law that protects the privacy of student education records, follow this link: https://studentprivacy.ed.gov/faq/what-ferpa

By filing this form, you are filing a complaint with the Springbrook Schools Compliance Officer alleging that PII has been disclosed to or accessed by an unauthorized person.

Please complete the form thoroughly, including sufficient detail that will allow the complaint to be investigated.

After the Compliance Officer review is completed, you will receive an email informing you of the action(s) taken as a result of your complaint.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Please select the role of individual making the complaint.*

Parent/GuardianPrincipalStudentSuperintendentTeacherOther District Employee
Please select the date that the violation occurred. *

MonthDayYear
Date
Please list the name of the individual(s) involved. If you are listing multiple names, please separate each name with a semi colon (for example: John Smith; Jane Jones)*
Please indicate which school(s) or building(s) are involved (select as many as applicable).*

Kids Unlimited PreschoolThe School at Springbrook Education Program - residential studentThe School at Springbrook - day studentHighland (GEMS)Hilltop (GEMS)LeChase (Golisano)Snell (GEMS)Sunshine (GEMS)Susquehanna (GEMS)Taylor (GEMS)Wright (Golisano)
Please select the type(s) of Personally Identifiable Information (PII) disclosed. If an item is not on the list, you will have the opportunity to list the item(s) in response to the next question.

Parent NameParent AddressStudent AddressStudent ID NumberStudent GradesStudent IEP or 504 informationStudent Phone NumberStudent NameStudent Photo
If not noted above, please describe the specific PII that was disclosed. Please separate each item with a semi colon. IMPORTANT: Please do not reference the actual PII that was disclosed. Please only reference the PII by name (i.e. "the student's social security number" or "the student's birthdate.")
Please describe how the specific Personally Identifiable Information(PII) was disclosed.*
Please provide the names and contact information for any additional individuals who may be able to provide supporting information.
If you contacted any school official(s) in an attempt to discuss or resolve this matter, please describe what happened.
Please provide any additional information you feel necessary to complete your complaint.
Do you want the Compliance Officer to keep your name and contact information confidential? Some complaints may not be able to be investigated if the complainant seeks to remain confidential.*

YesNo
Certification: I certify that the information I have provided is true to the best of my *knowledge.*

YES, I certify that the information I have provided is true to the best of my knowledge.NO, I do not certify that the information I have provided is true to the best of my knowledge.
Should be Empty: