The forms on the following pages are provided to assist the District in relation to operation of video and audio equipment in certain special education classrooms and other settings as required by law.


Request for the Installation of Video and Audio Recording Equipment

A parent, Trustee, or staff member, as defined by law, may request that video- and audio-recording equipment be installed in a self-contained classroom or other special education setting that meets the requirements of state law for such video and audio monitoring. In order to make a request, complete the information below and submit this form to the campus principal or designee. For more information, see EHBAF(LEGAL) and (LOCAL).

Requestor's information:

Name (print):

Phone number:

E-mail address:

I am a:?Parent?Trustee?Staff member

If a parent/guardian, child's name:


Classroom/setting (room number or teacher's/related service provider's name):

To the best of my knowledge, this request meets the criteria in state law to require the District to conduct video and audio monitoring as required by law.

Signature: Date:

For Office Use Only

Principal's signature:

Date received:


Notice of Installation of Video and Audio Recording Equipment

Note: Before the District installs video and audio recording equipment in a self-contained classroom or other special education setting in accordance with Education Code 29.022, the District is required to provide advance written notice to all staff assigned to the applicable campus and to the parents of the students receiving special education services in the classroom or setting. For more information, see EHBAF(LEGAL) and (LOCAL).



As required by law, this letter serves as notice that the campus has received a request to install and operate video and audio recording equipment in the following location(s):

The video- and audio-recording equipment will be capable of covering all areas of the classroom or other special education setting, as required by law.

The inside of a bathroom or any other area in the classroom or setting in which a student's clothes are changed will not be visually monitored. However, audio-recording will be conducted in all areas of the classroom or other special education setting.

The sole purpose of video and audio monitoring is to promote the safety of students receiving special education services, and the recordings may not be used for any other purpose. Regular or continual monitoring of these recordings is prohibited.

The District will maintain the footage from these recordings for at least six months, as required by law.

Please contact the campus principal or designee with any questions.

[Note to school administrator: If the District has determined that the request requires placing video and audio equipment in multiple special education classrooms or settings, be sure to indicate all the locations subject to the request.]



This form is to be completed by a parent or guardian, on behalf of a parent or guardian, or by an employee who notifies the school of an alleged incident that occurred in a self-contained classroom or other special education setting where audio and video equipment is operational.

Upon receipt of this incident report form, appropriate District staff will begin viewing the footage recorded on the date(s) described below to determine whether any incident(s) as described below were recorded. If the recording documents an incident as defined by law, the District will release, on request, the recording for viewing by an employee or a parent or guardian of a student who is involved in the incident. Depending on the nature of the recorded incident, the District may also be required by law to release the recording for viewing to individuals described in EHBAF(LOCAL), including appropriate personnel or agents of the Department of Family and Protective Services and/or State Board for Educator Certification. For more information, see EHBAF(LEGAL) and (LOCAL). The release for viewing will occur only as allowed by federal and state law.

Contact Information:

I am a:? Parent? Staff member


Home phone: Mobile phone:

E-mail address:

Date(s) of alleged incident(s):

Time(s) of alleged incident(s):

Location(s) of alleged incident(s):

List any witness(es):

Describe the incident(s) as clearly as possible, including names of individuals involved and any District policy or law you think may have been violated. (Attach additional pages if more space is needed.)

I am requesting to view the applicable recording.

I hereby certify that the information I have provided is true, correct, and complete to the best of my knowledge and belief.

Name (print):

Signature: Date:

United ISD


LDU 2016.05

DATE ISSUED: 9/7/2016