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.

Today's Date:required

Must contain a date in M/D/YYYY format

Date of Incident:required

Must contain a date in M/D/YYYY format

I wasrequired

Bullied

A witness of bullying

Other, please specify below

Other

Location: Please specify where this incident took place, such as classroom, gymnasium, bus.required

Names of the people involved, school, and their role (w=witness; v=victim; p=participant; o=other)

Name, School, Role for any persons involvedrequired

Description. Please provide as many details as possible.required

Does an adult know about this incident?required

Yes

No

Who is the adult?required

My name is (THIS FIELD IS OPTIONAL)

Grade (THIS FIELD IS OPTIONAL)

What is the phone number you can be contacted at? (THIS FIELD IS OPTIONAL)

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In This Section

In This Section

Bullying Incident Report