Voice Recognition

Report Form

Bullying Incident Reporting Form
The Chenango Forks School District is committed to providing a safe environment to all members of our community.   Despite our best intentions, incidents between students do occur at times.  If you wish to report an incident, complete this form and use the SUBMIT button to send it to the building Dignity Act Coordinator.  You may submit this form anonymously if you prefer.  Feel free to contact the Dignity Act Coordinator for additional information or assistance at any time.  Every reported act of bullying will be investigated. Parents of targets and aggressors will be contacted in cases of confirmed bullying.

Person Reporting Incident (if known): If you wish to remain anonymous, please leave this blank.
E-mail address (if preferred method of communication):
Phone Number:
About the Person Reporting:





Date of Report
Date/Time of Incident(s):
Name of Student Targeted
Age:
Grade:
School:
Name of Alleged Aggressor(s) (if known):
Age:
Grade:
School:
Name of Witnesses (if known):
Exact Location of Incident(s):
Briefly Describe Injury:
What did the aggressor(s) say or do? (be specific)
Have there been similar bullying incidents involving the aggressor and targeted student in the past?
If yes, briefly describe:
If the bullying involved electronic communications, is documentation available?
If yes, describe form of documentation
Was personal property stolen or damaged as a result of the incident?

Please describe item(s):
Is there any additional information you would like to provide?
To submit this form, please enter the solution to the simple math equation in the black box to the right of the equation, and then enter the SUBMIT button. It is not necessary to enter your name and email if you prefer to remain anonymous.
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To validate your submission, please type the answer to the question.

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