Submit an Unauthorized Disclosure/Breach Complaint Form

*Please note, required fields are in red.

Please use the following form to file a complaint about a possible breach or improper disclosure of data using this online form. This form is designed for use by Long Beach City School District parents, eligible students (at least 18 years of age or older), principals, teachers, and other employees.

Please do NOT include any information in this form that would constitute sensitive information (e.g. passwords, Social Security numbers, etc.).
First Name:
Last Name:
Phone Number:
Email Address:
Role:
Building:
Description of Event(s) (Please Include Relevant Dates):
Description of Possible Disclosed Data:
Description of How Reporter Learned of Possible Disclosure:
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Submit an Unauthorized Disclosure/Breach Complaint Form

Please do NOT include any information in this form that would constitute sensitive information (e.g. passwords, Social Security numbers, etc.).

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