Bullying Incident Report
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Bullying Incident Report
Please use this form to report any bullying incident that you have been victim to or witnessed.
YOU ARE ENCOURAGED TO CONTACT THE SCHOOL OF THE STUDENTS INVOLVED IN CASE OF AN EMERGENCY.
High School: 716-807-3600
Middle School: 716-807-3700
Intermediate School: 716-807-3825
Drake Elementary: 716-807-3725
Ohio Elementary: 716-807-3800
Spruce Elementary: 716-807-3850
PLEASE NOTE: False reporting of an incident is against state law and school policy 7311. Section 240.50 of the New York State Penal Law states: A person is guilty of falsely reporting an incident when, knowing the information reported, conveyed or circulated to be false or baseless, he/she initiates a false report or warning of an alleged occurrence or impending occurrence of a crime, catastrophe or emergency under circumstances in which it is not unlikely that public alarm or inconvenience will result. This is a Class A Misdemeanor.
1.
Today's Date:
*
mm/dd/yyyy
2.
Date of Incident:
*
mm/dd/yyyy
3.
I was
*
Bullied
A witness of bullying
Other, please specify
4.
Location: In which building did this incident take place?
*
Administration Building
NTHS
NTMS
NTI
Drake Elementary
Ohio Elementary
Spruce Elementary
Other, please specify
5.
Location: Please specify where this incident took place, such as classroom, gymnasium, bus.
*
6.
Names of the people involved, school, and their role (w=witness; v=victim; p=participant; o=other)
*
Name
School
Role
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
7.
Description. Please provide as many details as possible.
*
8.
Does an adult know about this incident?
*
Does an adult know about this incident?
*
Yes
No
9.
Who is the adult?
*
10.
My name is (THIS FIELD IS OPTIONAL)
11.
Grade (THIS FIELD IS OPTIONAL)
12.
What is the phone number you can be contacted at? (THIS FIELD IS OPTIONAL)