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Ripperdan- Student Concern Reporting Form
Students have a right to report, and should report, bullying or harassment at school, whether they are a bystander/witness or a victim. This form will be shared with your school site administrators.
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* Indicates required question
Email Address
*
Your answer
Your Name (Optional, if you feel comfortable sharing)
Your answer
Were you a victim of a student rights violation, such as bullying or harassment?
*
Yes
No
Did you witness a student rights violation, such as bullying or harassment?
*
Yes
No
Did someone else tell you about a student rights violation, such as bullying or harassment?
*
Yes
No
If someone else told you about this violation, what is their name? (optional, if you feel comfortable sharing):
Your answer
Did anyone else witness this violation?
Yes
No
Clear selection
Please tell us who else (names) was there? (optional, if you feel comfortable sharing):
Your answer
Did you or someone report this to an adult?
Yes
No
Clear selection
If yes, please tell us who you reported this to:
Your answer
What is your concern?
Your answer
Was this committed by a staff member or another student?
*
Staff
Student
When did this happen?
In the morning
At break/recess
At lunch
At dismissal
After school
On the bus
Other:
Clear selection
Where did this happen?
At the bus stop
On the bus
Classroom
Cafeteria
Hallways/passing
Playground
After School Program
On social media
Other:
Clear selection
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This form was created inside of Madera Unified School District.
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