Incident and Bullying Report Form
C.A.T.S. - Comprehensive Anonymous Tip System is available for students, parents and our community to report their concerns regarding the safety of a student. This site is monitored regularly by school district administrators. Depending on the seriousness of the perceived threat or concern, this tip may be reported directly to the police department.
Today's Date *
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Date of Incident *
MM
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DD
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YYYY
The incident took place... where? *
Your answer
I was *
Names of people involved, school attended, and their role *
Your answer
Person 1 - Name and School *
Your answer
Person 1 - Role *
Person 2 - Name and School
Your answer
Person 2 - Role
Person 3 - Name and School
Your answer
Person 3 - Role
List any other persons involved and their role in this incident
Your answer
Description of the incident (Be specific when describing the event) *
Your answer
Does an adult (at school or in your neighborhood) know about this incident? *
What is the name of the adult?
Your answer
What is your idea on how to handle this incident?
Your answer
My name is (This information is optional)
Your answer
Grade (This information is optional)
Your answer
What is the phone number that you can be contacted at? (This information is optional)
Your answer
Email address (This information is optional)
Your answer
Confidentiality Statement: This form is being used to facilitate the safety of you or another student and to provide a confidential avenue to report your concerns. The information you provide will be kept in the strictest confidence. However, we are bound by law to share with law enforcement officials any information that indicates that you or another person have committed or are about to commit an act which may be harmful to yourself or others. False reporting of an incident is against state law and school policy. Section 240.50 of the New York State Penal Law states: A person is guilty of falsely reporting an incident where knowing the information reported, conveyed or circulated to be false or baseless, he/she initiates a false report warning or an alleged occurrence or impending occurrence of a crime, catastrophe or emergency under circumstances in which it is not likely that public alarm or inconvenience will result. This is a Class A Misdemeanor. I understand the above.
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