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

Student

Parent / Guardian

Staff Member

Community Member

Contact Information of Person Filling out this form:

Name

Answer Required

Contact Phone Number

Answer Required

Contact Email Address

Answer Required

Incident Information

Name(s) of individuals involved:

Answer Required

Is the person(s) involved a (check all that apply)

Answer Required

Student

Employee

Description of alleged bullying, harassment, and discrimination:

Date(s) of the alleged incident(s):

Answer Required

Where did the incident(s) take place:

Answer Required

Explain what happened:

Answer Required

Were there any witnesses?

Answer Required

Yes

If YES please list the name(s) of the individual(s):

Answer Required

Has the incident been previously reported?

Answer Required

Yes

If YES, when and to whom?

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

Yes

Name of person filling out this form:

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.

Alexander Central School District

Please fix the highlighted areas below before submitting.

Dignity for All Students Act