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Malone Central Elementary Online Bullying/Harassment Form
Malone Central School District is committed to providing a safe, supportive learning environment for all students. Bullying incidents can be reported directly to a trusted staff member, and/or DASA coordinator at your school. This online form will be used by all Malone Elementary students and their parents to report being bullied/harassed or by someone witnessing a student being bullied. The school noted on the submission will review and investigate once it has been received and documented.
Please sit with your Son/Daughter when filling this form out.
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.
Elementary School that the Bullying/Harassment is taking place?
Date when bullying or harassment took place?
Name of Parent/Guardian reporting the incident and your students name?
Name of Student and grade level (if possible) who is doing the bullying/harassing:
Name of any witnesses:
Where did the bullying/harassment Occurred?
Cyberbullying (on an electronic device, cell phone, computer ect.
What Happen? (Check all that apply)
Someone called me names
Someone looked at me funny
Someone was mean to me
Someone took something of mine
Someone told me to do something I didn't like
Someone broke my stuff
Someone destroyed my property
Someone used words that hurt me
Someone lied about me
Someone stole something from me
Someone threatened me
I was left out of a group
Someone put their hands on me
Someone physically hurt me
Please describe the bullying/harassing incident in as much detail as possible
How often has this occurred?
By completing this form, you are verifying that your statements are true and accurate to the best of your knowledge.
If you have trouble completing this form and would like to speak with someone, please contact your son/daughters school and ask to speak to the DASA Coordinator.
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This form was created inside of Malone Central School District.