Video Documentation and Surveillance Viewing Request Form                                                          Attachment III


Contact Information




Full Name (Last, First, M.I):


Work Phone:


E-Mail Address:



Reasons for Request




Recorded Video

Live View

Extended Live Viewing





Describe the camera location (i.e., building, interior, exterior, warehouse, point of sale, etc.).





Describe the purpose and goal for video request.



Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete.

Name (printed):







Approval and Tracking


Please Circle:

Approved / Disapproved




Director of University Police:




Request Fulfilled Date:


Supervisor, Access Services


This document is FOR OFFICIAL USE ONLY.  It contains information that may be confidential under Chapter 418 of the Texas Government Code and may be exempt from public release under the Texas Open Records Act/Public Information Act (Texas Government Code Chapter 552) and Freedom of Information Act (5 U.S.C. 552). This document is to be controlled, handled, transmitted, distributed, and disposed of in accordance with university policy relating to open records information and is not to be released to the public or other personnel who do not have a valid "need-to-know" without prior approval of the Director, University Police Department, Texas State University-San Marcos.