Sherburne-Earlville Bullying Report Form

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This form CAN be completed by anyone who is concerned about an incident.
This form MUST be filled out by any staff member who has been made aware of an incident.

Date of this report: *

YYYY

Name of person filing this report: *

Identification of person filling out this form:

Check all that apply

I am the alleged victim

I am the parent/guardian of the alleged victim

I am a staff member reporting an alleged incident

I am a witness to an alleged incident

I was told about an alleged incident

Other:

Required

The best way to reach me is:

Enter your phone number, email or room on campus

Identify alleged victim:

Enter student's name and student's grade

Identify alleged offender(s):

Enter names and indicate student or adult for each

Describe alleged offense(s):

Include where and when offense(s) occurred

Classify alleged offense(s):

Check all that apply

Physical (i.e. hitting, tripping, kicking, pushing, damaging property, etc.)

Social/Emotional (i.e. excluding, spreading rumors, alienating, ostracizing, etc.)

Verbal (i.e. name-calling, teasing, intimidating, threatening, taunting, etc.)

Cyberbullying (i.e. insulting or threatening through texts, emails, social media, etc.)

Other:

Required

Was anyone physically injured?

Yes, and medical treatment was required

Yes, but medical treatment was not required

Yes, but I am unsure of medical treatment was required

Unsure

Required

Is this the first time this has happened?

Yes

Unsure

Required

If you answered "No" to the previous question, please provide dates of previous incident reports and to whom they were reported.

Bullying Report Statement

The Sherburne-Earlville Central School District is committed to ensuring the safety and well-being of all students, faculty and staff. All bullying reports are taken seriously and will be reviewed as soon as possible by the Superintendent and SECSD Administration Team.

In addition to submitting this report, you may call the District Office at 607-674-7300 to speak to someone directly. More information regarding the District's response to bullying and the Dignity for All Students Act is available on our website at https://www.secsd.org/Bullying.aspx.

If you feel there is an immediate threat to yourself or others, please call local law enforcement.

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