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Alexander Central School District



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Dignity for All Students Act


Dignity for All Students Act 

Bullying, Harassment and Discrimination Complaint Form 

The purpose of this form is to notify the district of an incident, or series of incidents, of bullying and/or harassment so appropriate steps can be taken.

Person filling out this form: Please check one box
Answer Required

Contact Information of Person Filling out this form:

Incident Information

The basis of the actual or perceived bullying, harassment or discrimination is: (Check appropriate information)
Answer Required
Is the person(s) involved a (check all that apply)
Answer Required

Description of alleged bullying, harassment, and discrimination:

Were there any witnesses?
Answer Required
Has the incident been previously reported?
Answer Required

"I certify that all statements on this form are accurate and true to the best of my knowledge."

Accept above statement:
Answer Required

Any supporting documentation (i.e. copies of emails, notes, photos, etc.) can be emailed to: 

[email protected] or delivered directly to the High School Main Office.