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Bullying/Harassment Report
The link below is provided for you to inform the District about bullying or harassment incidents that you have either experienced or witnessed. The form can be submitted anonymously and will be seen by a DASA coordinator. These situations can occur in school or out of school. Please provide as much information as you can so that the problem can be addressed appropriately.
Dignity for All Students Policy 7550:
http://go.boarddocs.com/ny/orchard/Board.nsf/goto?open&id=BMTTMH780A4B
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* Indicates required question
Today's Date
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MM
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YYYY
(Optional) My name is:
Your answer
School
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Choose
Orchard Park High School
Orchard Park Middle School
Eggert Elementary School
Ellicott Elementary School
South Davis Elementary School
Windom Elementary School
(Optional) Grade
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PK
K
1
2
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(Optional) What is the phone number you can be contacted at?
Your answer
Date of Incident
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MM
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DD
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YYYY
I was:
Bullied/harassed
A witness of bullying/harassment
Other:
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Where did this incident take place?
Your answer
Please list the name of the people involved, the school and their role.
Roles:
W= Witness
V=Victim
P=Participant
O=Other
Example: John Smith, Orchard Park Middle School, W
List names below.
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Your answer
Description - give as many details as possible.
*
Your answer
Does an adult know about this incident?
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Yes
No
If yes, who is the adult?
Your answer
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