Dignity Act Reporting Form
The Dignity for All Students Act prohibits acts of harassment and bullying, including cyberbullying and/or discrimination, by employees or students on school property or at a school function, including but not limited to such conduct as those based on a student’s actual or perceived race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender (defined to include gender identity or expression) or sex (Education Law §12[1]). Cyberbullying is defined as harassment or bullying which takes place through any form of electronic communication (Education Law §11[8]).
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Date of this report *
MM
/
DD
/
YYYY
Your name
If you choose to submit anonymously, please leave blank. Including your name will allow us to follow up with you if we need more information during this process.  
Your role in the school community *
Required
Your email address
Your phone number
Name of target *
Name of alleged offender *
What was your involvement in the incident? *
Required
Which school does the alleged offender attend *
Where did the incident happen? *
Required
Type of Incident *
Required
Description of incident(s) *
Describe the specific nature of the incident.  What happened? Be as specific as possible. What did the alleged offender say or do? 
Witnesses and contact information
Witnesses, if any, or others who should be contacted with knowledge vital to this investigation. Please include contact information (e.g. phone number) if possible.
Types of bias involved (if known)
Impact *
Describe the impact this incident has had on the target
Is the situation still occurring? *
What do you think should be done in this situation? *
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