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Bullying Reporting Form
Dignity for all students (Bullying, Harassment and Hazing)
Date of Incident
MM
/
DD
/
YYYY
Name(s) of alleged offender(s) (Bully) if known: *
Name(s) of victim(s) *
Name(s) of possible witnesses/bystanders:
Description of incident: *
When did this happen? Is this the first time?
Did physical injury result from this?
Name of person reporting incident (may be anonymous). If you leave your name you will be contacted by Mr. Swick (Principal - jswick@towschool.org) or Mrs. Dornburgh (DASA Coordinator - ddornburgh@towschool.org 315-369-3002) as soon as possible.
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