| ATTACHMENT B |
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Any student may prevent the public disclosure of directory information from his/her university records by
completing this form and submitting it to the Vice President, Student Affairs Office. The executed form
is valid throughout the student's enrollment at California State University, San Bernardino. The complete policy on the Federal Educational Rights and Privacy Act of 1974 and Executive Order 796 is available in the Office of the Vice President, Student Affairs. Directory information refers to the information in student records which may be released to anyone unless students advise the university in writing that such information concerning them may not be released. At this university, directory information includes: |
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Name Address Telephone No. Date and place of birth Major field of study Current unit load Extent of participation in university sports/student activities Dates of attendance, degrees/awards received at CSUSB Educational institutions previously attended. |
| I, (Print Name)______________________________________________________________, request that California State University, San Bernardino, NOT release any directory information from my university records in accordance with provisions of the Family Educational Rights and Privacy Act of 1974 and Executive Order 796. |
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_______________________________ Date |
_______________________________________________ Student's Signature _______________________________________________ Student ID Number |