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Disclaimer
This is a private intake form, not an anonymous form. I will protect your privacy as much as possible, but I need to know who is submitting information so we can avoid relying on rumor, speculation, or unverifiable claims. Names and identifying details will not be shared publicly or with the larger group without permission. Please do not include student names, graphic descriptions, private medical information, or identifying details about minors in this form. If your concern involves suspected child abuse, sexual misconduct involving a student, or a current safety concern, please report directly to law enforcement, CPS, VDOE/licensing, Title IX, or another appropriate official channel. This form should not be the only place serious safety information goes. If your information involves a settlement agreement, NDA, or confidentiality provision, please do not upload or share anything you are not legally comfortable sharing. For the Albemarle County Police Department (Virginia) non-emergency dispatch, call (434) 977-9041. Anyone may report suspected child maltreatment to Albemarle County Department of Social Services by calling 434-972-4010. Legal Aid: https://www.justice4all.org/
Name
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First Name
Last Name
Email
*
example@example.com
Your connection to ACPS
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Parent/Guardian of current ACPS student
Parent/Guardian of former ACPS student
Current ACPS teacher/staff
Former ACPS teacher/staff
Current ACPS student age 18+
Former ACPS student
Community Member
Administrator for ACPS current or former
Other (Explain below)
If you chose Other please explain
Do you need your involvement kept private outside the intake team? Intake team is a small group of concerned adults with personal connections to the district, NOT ACPS employees
*
Yes
No
Please ask before sharing
Not sure yet
Are you comfortable communicating in English
Yes
No
English or Native language is fine
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Which best describes the information you are sharing?
*
I personally experienced this
I personally witnessed this
I reported this to ACPS
I helped someone report this to ACPS
I helped someone report this to ACPS
I heard this from someone else
I know someone who may have firsthand information
I am submitting a public-records lead
I am submitting policy-related information
Other
How would you categorize the concern?
*
Student-safety concern
Staff-student boundary concern
Closed-door or one-on-one staff/student concern
Sexual misconduct or grooming concern
Title IX concern
Mandatory reporting concern
Failure to respond to parent/guardian report
Failure to respond to staff report
Concern escalated to school administrator with no meaningful response
Concern escalated to district leadership with no meaningful response
Concern escalated to HR with no meaningful response
Concern escalated to Title IX with no meaningful response
Concern escalated to School Board with no meaningful response
Transfer or reassignment after complaint/concern
Quiet resignation/separation after complaint/concern
Settlement/NDA/payment-related concern
Retaliation or intimidation after reporting
Policy gap
Public records / FOIA lead
Other
Is there any current safety concern involving a student or staff member?
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Yes
No
I'm not sure
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Approximate date or school year. Examples: “Fall 2022,” “March 2024,” “2021–2022 school year.”
*
Which school, department, and/or ACPS office was involved?
*
You may use a general description if you do not want to name a school yet. Example: middle school, northern elementary school
Who was contacted or notified?
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Teacher/staff member
Principal
Assistant principal
School counselor
School resource officer/security
HR
Title IX office
Superintendent’s office
School Board member
Full School Board
Law enforcement
CPS
VDOE/licensing
Other outside agency
No one was contacted
I’m not sure
If you are comfortable, list the names or titles of people/offices contacted.
Titles are fine if you prefer not to use names.
How was the concern reported or communicated?
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Email
Text message
Phone call
In-person meeting
Written complaint
Title IX report
HR report
School Board public comment
Letter
Online form
Law enforcement/CPS report
Other
Was there a response from ACPS?
*
Yes
No
Partial/incomplete response
I don’t know
Briefly describe the response or lack of response.
Please keep this general. Focus on dates, offices contacted, follow-up attempts, and whether a response occurred. Do not include student names or graphic details.
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Next
Are there records or materials that could help verify the timeline?
Emails
Text messages
Letters
Screenshots
Meeting notes
Calendar invites
Report numbers
Board meeting records
Public records
Settlement/payment-related records
Policy documents
Witness names/titles
I do not have records, but someone else may
I do not have records
Other
Are you willing to share documentation privately if needed?
Yes
Maybe, but I want to talk first
No
I need legal advice first
I am not sure
Optional file upload
Browse Files
Drag and drop files here
Choose a file
Please redact student names, identifying details about minors, private medical information, and anything covered by an NDA or confidentiality agreement unless you have legal guidance. Emails, screenshots, letters, public records, meeting notes, and report numbers may help establish a timeline. Allowed files: PDF, JPG, PNG, DOCX, TXT.
Cancel
of
Do you need the contact information for a lawyer who as agreed to work with parents/guardians in these issues?
Yes
No
Unsure
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Has this concern been reported to any outside agency?
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Law enforcement
CPS / child protective services
VDOE
Educator licensing authority
Title IX / civil rights office
Attorney
Reporter/media
Other
Not reported
If reported, do you have a report number, case number, date, or agency contact?
Are you willing to speak directly with an attorney, investigator, agency, or other appropriate official if needed?
Yes
Maybe, but I want to talk first
No
I’m not sure
Back
Next
Please describe the concern in general terms.
Please do not include student names, graphic details, private medical information, or identifying details about minors. Focus on what happened generally, when it happened, who/which office was contacted, whether ACPS responded, and what records may exist.
What outcome or follow-up do you believe is needed?
Public records / FOIA follow-up
Policy review/change
Independent investigation
Outside agency report
Legal review
Board accountability
Pattern tracking only
I am not sure
Other
Is there anything else you want the intake team to know about privacy, safety, retaliation concerns, or how to contact you?
Optional
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Next
Please acknowledge:
*
I understand this is a private intake form, not an anonymous form.
I understand this form is not a substitute for reporting suspected child abuse, sexual misconduct, or current safety concerns to law enforcement, CPS, VDOE/licensing, Title IX, or another appropriate official channel.
I understand that my name and identifying details will not be shared publicly or with the larger group without permission.
I understand that information submitted may be used to identify patterns, guide public-records requests, organize a timeline, or determine appropriate follow-up.
I understand that information will not be treated as verified fact unless it can be documented or confirmed through appropriate sources.
Signature
*
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