MS/HS Report Bullying Form

Bullying Reporting Form
New York's Dignity for All Students Act took effect July 1, 2012.

For more information on DASA, visit the state's website by clicking  HERE.

If you or your child has experienced bullying, please use complete the form below to report the instance(s) of bullying behavior.

Date of Incident:
Time of Incident:
Where did the incident occur?
Who was bullying, harassing, intimidating or causing harm? (Include first name, last name and grade if known):
Who was the person being bullied, harrassed, intimidated or being harmed?
In your own words, describe the incident. Give as much information as possible, including witnesses, if any:
Have you told anyone?
Your name (optional):
If you would like someone to contact you about this, add your phone number or email address here (optional)
To submit this form, you must put the ANSWER to the simple math problem in the box indicated below

To validate your submission, please answer the following math problem:

captcha math problem