Malone Middle School Bullying & Harassment Anonymous Incident Report

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If you have any information regarding bullying/harassment and would like to report this information anonymously, please fill out the following form to the best of your ability and click submit. Please note: Making false allegations, providing discriminatory statements and making defamatory statements is prohibited and engaging in such activity will be reported to the appropriate authorities.

If you fear that a student is in immediate danger, please call the Malone Village Police Department at 483-2424, the New York State Police at 483-5000, or 911.

Person making the report: [OPTIONAL]

Contact information: [OPTIONAL]

Target/victim's name (first and last): *

Target's grade: *

Alleged bully's name (first and last): *

Alleged bully's grade: *

Name of witness #1:

Name of witness #2:

Date of incident: *

YYYY

Time of incident: *

Time

Frequency of incidents: *

How often have you witnessed this type of behavior?

Where did the incident happen? *

on school property

on a school bus

cyberbullying (on and electronic device, cell phone, computer, tablet)

at a school sponsored event off school property

on the way to/from school

Required

Which of the following best describes what happened? *

teasing

intimidation

physical violence

destruction of property

social exclusion

sexual, religious, or racial harassment

theft

spreading rumors

threats

public humiliation

stalking

cyberstalking/cyberbullying

Required

Describe what happened: *

If witnesses were involved, describe their role in the incident: *

List any evidence available of the bullying/harassment (letters, texts, posts, photos, etc.): *

Submit

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