Dignity Act Reporting Form

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The Dignity for All Students Act amends Education Law to put in place procedures for creation of a school environment free of discrimination and harassment. "The legislature finds that students' ability to learn and to meet high academic standards and the school's ability to educate its students, are compromised by incidents of discrimination or harassment..."

The District condemns and prohibits all forms of discrimination and harassment of students based on race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender, or sex by school employees or students on school property and at school sponsored activities and events that take place off school property.

If you feel that a school employee or student has violated the protections assigned under the Dignity Act, please fill out the form below. All forms must contain all the information. Forms completed anonymously will be discarded. Contact information must be complete.

Name of individual making this report? *

In which building did this incident take place? *

High School

Middle School

Guardino Elementary

Bashaw Elementary

Other:

Name of person(s) being harassed or discriminated against? *

Contact Phone Number? (for parent or guardian if completed by student) *

Contact Email Address

Under The Dignity Act, the individual(s) was harassed or discriminated against based on the following (check those that apply): If none apply check bullying and the incident, while not falling under the Dignity Act, will be addressed. *

Actual or perceived race or color

Weight

National Origin

Ethnic Group

Religion, religious practice

Disability

Sexual orientation

Gender or sex

Bullying (it does not fall into any of the above categories under the Dignity Act)

Required

Describe the incident, what did the alleged offender say or do? *

Date of incident *

YYYY

Where did the incident occur? *

Classroom

Playground/recess

Field trip

Cafeteria

School Bus

Library

Hallway

On the way to / from school

Electronic / Cyberbullying

Locker Room

Auditorium

Other:

Name(s) of individuals harassing/discriminating? *

Witnesses? (if any)

Have you had issues with this student/employee previously? *

Yes

If you had a previous issue with this individual, what was it?

If you had a previous issue with this offender, was it reported through this system?

Yes

Clear selection

Is there any additional information you would like to provide?

Even though it will be completely up to the District to resolve this matter, I feel the best course of action would be?

Educate the offender.

Have a counselor meet with the offender.

Have the offender meet with the counselor and the target to apologize and resolve the issue

Send to the principal for discipline.

Clear selection

What grade level range is the target (the alleged victim of discrimination/harassment) in? *

K-5

6-8

9-12

By pressing "Submit" I am affirming under penalty of perjury, I understand that in a written instrument, any person who knowingly makes a false statement which such person does not believe to be true has committed a crime under section 210.45 of NYS Penal Law. Untitled Title

Submit

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