Print
UCLA Procedure 603.1 :
Attachment D
UCLA Information Disclosures Log Sample
| DATA SUBJECT (NAME) | UCLA DEPARTMENT: | ||||
| DATE OF DISCLOSURE | PERSON RECEIVING INFORMATION (Name, Title, and Business Address) |
INFORMATION DISCLOSED (Be Specific) |
Purpose OF DISCLOSURE (Be Specific) |
DISCLOSURE | |
| REPORTED BY | AUTHORIZED BY | ||||