Student Statement Form
Jason Lee Middle School Student Statement Form. 
Thank you! Please be as detailed as possible. A Jason Lee counselor or administrator will be in contact with you soon to follow-up with your report. 
Email *
Date *
MM
/
DD
/
YYYY
First name
 *
Last name
 *
Grade *
Time *
Time
:
Student(s) you are reporting *
Where did it happen? *
What happened? Please be as specific as possible. *
When did it happen? *
Why did it happen? *
Did you tell them to stop? *
Have you reported this issue before? *
How long has this been an issue? *
Student Witness? (add none if you do not have any witnesses) *
What staff members know about this?  (add none if you do not have any staff members that know) *
What do you need? How can we best help you?  *
Would you be willing to have peer mediators help you problem solve?
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Vancouver School District.

Does this form look suspicious? Report

Google Forms