Parent Concern
Your Information
Your Name
Your Email Address
Your Callback Number
Alternative Phone number
Street Number and Name
Apt, Suite, Etc. (Optional)
City
State
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OH
IN
KY
Zip Code
Student Information
Name of Student
Grade
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Pre-K
K
1
2
3
4
5
6
7
8
9
10
11
12
School Name
Concern Information
Concern Categories
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Academic Concerns
Building Concerns
CPS Concerns
Student Concerns
Teacher/Principal Concerns
Does this concern involve physical violence or the threat of physical violence/injury?
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Yes
No
Please describe.
Has there been a threat of hurting themselves/others in connection with this concern?
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Yes
No
Please describe
Concern Description
Provide a complete description/explanation of the concern, including the date of the incident on which the concern is based, names of studets or others responsible or involved in the incident, names of witnesses and all other relevant facts.
Additional Information
Describe any earlier efforts to resolve this matter or the reasons no such efforts were pursued:
What specific remedy or corrective action are you seeking?
Hidden Info
School ID
Notification Source
Button Color
Hover Color