Bullying Report Form
 
Page 1 of 1
 
 Bullying Report Form 

 
 

Confidentiality Statement



This form is being used to facilitate access to DASA Coordinators Mrs. Danna and Mrs. Rhoades and to provide a confidential avenue for reporting bullying incidents.

The information you provide will be kept in the strictest confidence.

However, we are bound by law to share with law enforcement officials any information that indicates that you or another person have committed or are about to commit an act which may be harmful to yourself or others.

False reporting of an incident is against state law and school policy.

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.
*
  Select Date
mm/dd/yyyy
   
2.
*
  Select Date
mm/dd/yyyy
   
3.
Select at least 1.
 
  
  

    
   
4.
 
   
5.
 
    
Person 1   
Person 2   
Person 3   
Person 4   
Person 5   
Person 6   
Person 7   
Person 8   
Person 9   
Person 10   
   
6.
*
 
   
7.
 
   
8.
 
   
9.
 
   
10.
 
   
11.
 
   
 
 
 
 Done  Save  Cancel