Name: ______________________________________________________________________
FIRST MIDDLE OR MAIDEN LAST
Social Security Number: _________________ Year of Entrance: _______________
I am aware
of, or have read, the Berkeley Campus Policy Governing Disclosure
of Information from Student Records. I have been notified that
the School of Social Welfare considers the items listed below to
be matters of public record, and that this information will be released
upon written request unless I notify the School of Social Welfare,
in writing, that the information should be withheld. In order for
my request to be honored, I must submit this form before the end
of the second week of classes of the term fro which it is to be
effective. I understand that failure to notify the School of Social
Welfare about information to be withheld assumes that approval is
given to release this information.
A request to withhold release of public information does not prohibit
release of any information to University offices and personnel,
including field placement agencies, when such access is necessary
for the normal performance of their assigned duties.
Following is a list of the items considered to be public information.
Please indicate which items you wish withheld:
|
Item
of Public Information
|
Withhold
from Public Information |
Name
|
_____
|
Dates
of attendance
|
_____
|
Major
field of study
|
_____
|
Degrees
granted at Berkeley and award date
|
_____
|
Name
of most recently attended institution prior to Berkeley
|
_____
|
The above instructions will be followed for a period of time in
keeping with the School of Social Welfare's record keeping procedures
as explained in the School's policy, and do not apply to records
maintained by any other campus office.
Please return this form to the Graduate Assistant in 118 Haviland.
Signature: _____________________________ Date: ______________________
The Social Security number you provide on this form will be used
by the University to verify your identity. Disclosure is mandatory.
This notification is provided to you as required by the Federal
Privacy Act of 1974. The University's record-keeping systems were
established prior to January 1, 1975, pursuant to the authority
granted to The Regents of the University of California under Article
IX, Section 9, of the California Constitution. If you are a United
States Citizen and do not have a Social Security number, apply for
one through the nearest district Social Security Office and notify
the Graduate Division when you receive it. If you are not a United
States citizen and live in another country, it is not necessary
for you to secure a Social Security number.
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