Student Safety & Well-Being Reporting Form

Help Keep Our School Community Safe
This form is a dedicated space for students to report serious concerns that could affect the safety of our school. If you see or hear something that doesn’t feel right—whether it’s a social media post, a conversation, or a peer who seems to be struggling—please let us know.

What to Report Here:

Threats of violence or life-threatening behaviors.
Concerning social media posts or digital activity.
Behavior that makes you or others feel unsafe.

Note: For everyday issues like a broken locker, a messy bathroom, or minor classroom disagreements, please speak directly to a teacher or your School Principal.

Your Voice Matters
The Rochelle School District wants everyone to feel safe and supported. Often, students are the first to notice when a friend is in trouble or when something is wrong. By speaking up, you are helping us look out for one another. You can choose to remain anonymous (we won’t know who you are) or leave your name if you'd like a counselor or administrator to follow up with you.

Every report is taken seriously and handled with care according to District policy.

⚠️ Is this an emergency?

If there is an immediate threat or if someone is in danger right now, do not wait for this form to be read. Please call 911 or contact the Rochelle Park Police Department at 201-843-1515 immediately.

Location of the concerning behavior/action/message:*

Answer required for "Location of the concerning behavior/action/message:"

Midland School

BOE Offices

Cafeteria

Midland School Playground

Other, please specify

If you chose other, please briefly specify the concerning location/action/message:

Answer required for "If you chose other, please briefly specify the concerning location/action/message:"

Nature of Concern:*

Answer required for "Nature of Concern:"

Threat to building, student, staff, safety - If this is an immediate threat please call 911 now

Alarming social media post

Security Concern

Weapons

Other, please specify:

If you chose other, please briefly specify the nature of your concern:

Answer required for "If you chose other, please briefly specify the nature of your concern:"

Provide a detailed description with specific information (what happened, students name(s), grade level, date of incident, witnesses, exact source or location of concern) of your concern:*

Answer required for "Provide a detailed description with specific information (what happened, students name(s), grade level, date of incident, witnesses, exact source or location of concern) of your concern:"

Contact Information: This concern will be reported anonymously UNLESS you provide contact information below. Please know that allowing us to contact you may be helpful to us addressing and mitigating the concern as quickly as possible.

First Name

Answer required for "First Name"

Last Name

Answer required for "Last Name"

Email Address

Answer required for "Email Address"

Phone Number

Number Required

Please fix the highlighted areas below before submitting.

Student Safety & Well-Being Reporting Form