Log of access to confidential record




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LOG OF ACCESS TO CONFIDENTIAL RECORD

Child                   Date of Birth      

Last First Initial


The following persons have accessed these records:

Name (Please Print)


Purpose

Validation*

Date


     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     

     


     

     

     


* The custodian of the record must initial that picture identification has been presented by the person requesting access to the record.
These Early Intervention Records are to be maintained in a confidential manner in accordance with the Family Education Rights and Privacy Act (34 CFR Part 99), and the Individuals with Disabilities Education Act (34 CFR 300.560-300.576 and 34 CFR 303.460).


CMS/ES 1063


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