Somerville SEPAC Intake Form

Responses collected from this form will be used by the SEPAC leadership team to determine if a systemic problem exists within Somerville Public Schools.  We will then work in collaboration with the district to alleviate potential barriers to positive educational experiences. 

All identifying information is confidential and may not be disclosed without explicit permission from the informant.  The SEPAC will use this information to identify trends and patterns that exist within the district.. Information may only be shared from personal experience. No secondhand information is allowed. 

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Would you like to be contacted by a SEPAC board member to discuss this issue? *
Required
Name (optional if you want to be contacted)
Email address (optional if you wish to be contacted)
What is your child's age? *
Name of School: *
Name of program (if applicable)
What is the nature of your concern or question? *
Please include if this is a single event or an ongoing issue. Please refrain from using specific names of staff members and/or other students involved.  
Does your child have an IEP or 504? *
Required
Thank you for your response.  If you chose to be contacted by a SEPAC board member, remember to leave your name and email.  We recognize that no survey is perfect. Include any additional questions, comments or concerns you may have here.  
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