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UCLA Procedure 603.1 : Attachment B

Privacy Notice Information and Sample Wording

When an individual is asked to complete a form used to supply confidential or personal information, a written statement containing the following will be given to the individual, or included on the form unless the statement has been given to the individual during the previous twelve months.

  • The name of the campus department or office requesting the information.
  • The title and campus address of the person who is responsible for the maintenance of the information.
  • The University policy or other legal authority which authorizes the maintenance of the information.
  • Whether submission of the information is mandatory or voluntary.
  • The consequences, if any, of not providing all or any part of the requested information.
  • The principal purpose or purposes for which the information is to be used.
  • The individual's right to review records containing personal information maintained on him or her by the University.
  • Any known or foreseeable transfer to a governmental agency of the information which may be made.

A sample notice is presented below to assist departments in designing required notices. Notices should be approved by the Records Management Coordinator.

Privacy Notice

(Insert Appropriate Information Where Parentheses Appear)

The California Information Practices Act requires the University to provide the following information to individuals who are asked to supply information about themselves:

  • The principal purpose for requesting the information on the attached form is to- (Describe Purpose: e.g., permit parking, evaluate qualifications for employment, etc.).
  • This information is solicited in accordance with University policy adopted pursuant to Article IX, Section 9 of the California Constitution (or any other expressly numbered or dated policy, or state or federal law which you know requires the information).
  • Furnishing each item of information requested on the attached form is mandatory (except those items, if any, which are voluntary and which should here be noted). Failure to provide the requested information will delay or may prevent completion of the purpose for which the attached information is intended.
  • Information furnished on the attached form may be used by various University departments as required in the regular course of business, and may be transmitted to State and Federal government agencies if required by law.
  • You have the right to review personal information obtained about you in accordance with University policy and may contact the office of record maintaining such information or the Records Management Coordinator for more information concerning your rights.
  • The material on the attached form is maintained by ( Name of Office and Title of Responsible Officer.)