Supporting the K 12 Student Survivor Bill of Rights
This form allows survivors and families to share experiences related to sexual violence in K 12 schools, including interactions with school officials and Title IX processes. Stories may be used to support advocacy for the K 12 Student Survivor Bill of Rights.You may choose to remain anonymous and you may choose how, or if, your story is used. You are in control of what you share.You may stop at any time. You are not required to answer every question.
Do you understand that this form is voluntary and that you may choose to remain anonymous?
*
Yes
How may your story be used? Select all that apply.
As background research to support the K 12 Student Survivor Bill of Rights
In conversations with legislators or their staff
In written advocacy materials such as reports or testimony
On social media or public awareness campaigns
I am sharing for reference only, please do not use publicly
May your story be quoted directly?
Yes
No, please paraphrase only
No, please do not use any quotes
How would you like to be identified if your story is shared?
How would you like to be identified if your story is shared?
Anonymous
First Name Only
Initials Only
Other
How would you like to be identified if your story is shared? (Anonymous, First name, Full Name, Initials, Resident of) Please notate exactly in text.
Example: First Name: Emily resident of Florida
Which best describes your connection to this experience?
Survivor
Parent or Guardian
Educator or School Staff
Advocate or Supporter
Other
What grade level or age range does this story relate to?
Elementary
Middle School
High School
Was the incident disclosed to the school?
Yes
No
If disclosed, how would you describe the school’s response?
The Title IX process was clear and followed
The Title IX process was unclear
The Title IX process was not followed
No Title IX information was provided
Prefer not to say
Please share your story in your own words:
Share as much or as little as you feel comfortable. You may focus on what happened after disclosure and how the system responded.
Would you be open to being contacted if clarification is needed?
Yes
No
Contact Email:
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