Sackets Harbor Central School Dignity for All Students (Bullying, Harassment, and Hazing) Bullying Reporting Form
The Dignity for All Students Act amends Education Law to put in place procedures for the creation of school environments free of discrimination and harassment. The law is effective July 1, 2012. "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 including bullying, taunting, or intimidation."

Directions: Harassment, hazing, or bullying are serious and will not be tolerated. Please use this form to report alleged harassment, hazing or bullying that occurred on school property, at a school sponsored activity or event, on or off school property, on a school bus, or on the way to and/or from school. Any person (student, parent/caregiver, community member, faculty/staff member, etc.) observing, or being the target of bullying, hazing, harassment or perceived bullying, hazing, harassment activity reports the observation. Please complete this form. Contact the school for additional information or assistance. *This form may be completed anonymously, but doing so may limit the follow up that can occur.
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Name of person reporting the incident:
E-mail address
Relationship to target
Did you witness the incident?
Name, grade, and age of alleged target
Name(s) and grade(s) of alleged offender(s) (if known)
Names(s) and grade(s) of possible witness(es)
Where did the incident happen? Choose all that apply.
Check the statement(s) that best describe what happened. Choose all that apply.
What did the alleged offender(s) say or do? Explain in the space provided below.
Is this the first time? If not, explain what happened below.
Is there any additional information you would like to provide? Explain in the space provided below.
Signature of person reporting the incident:
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