Tonawanda CSD Bully Reporting Form

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New York State’s Dignity for All Students Act (The Dignity Act) seeks to provide the State’s public elementary and secondary school students with a safe and supportive environment free from discrimination, intimidation, taunting, harassment, and bullying on school property, a school bus and/or at a school function.

Additionally, under the Dignity Act, schools will be responsible for collecting and reporting data regarding material incidents of discrimination and harassment.

“Harassment” means: (1) the creation of a hostile environment by conduct or by verbal threats, intimidation or abuse that has or would have the effect of unreasonably and substantially interfering with a student's educational performance, opportunities or benefits, or mental, emotional or physical wellbeing; or (2) conduct, verbal threats, intimidation or abuse that reasonably causes or would reasonably be expected to cause a student to fear for his or her physical safety; and such conduct, verbal threats, intimidation or abuse includes but is not limited to conduct, verbal threats, intimidation or abuse based on a person's actual or perceived race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender or sex (Education Law Section 11[7]).

Any person who has reasonable cause to suspect that a student has been subjected to bullying, discrimination and/or harassment by an employee or student, on school grounds or at a school function can fill out this form.

Email *

Today's Date *

YYYY

Complainant Name *

Complainant Home/Cell Phone *

Please include area code and do not include parentheses or dashes.

Complainant Address *

School *

Middle/High School

Tonawanda Elementary School

Required

Target (Victim/s) Name *

Offender(s) Information *

Please list the offender(s) name, sex and grade/position if applicable.

Witness(es) Information

Please list the witness(es) name, grade/position if applicable and phone.

Where did the incident take place? *

On school property

At school-sponsored function off school grounds

Date and Approximate Time of Incident *

YYYY

Time

Incident Description of Discriminatory and/or Harassing Behaviors *

Type of bias is based on the person's actual or perceived (please check all that apply).

Race

Ethnic Group

Sexual Orientation

Color

Weight

National Origin

Religion

Disability

Gender

Sex

Not sure

Other:

Required

Description of the Incident *

Check all that apply.

Incident involved intimidating or abuse but no verbal threat or physical contact

Incident involved verbal threats but no physical contact

Incident involved physical contact but no verbal threat

Incident involved both verbal threat and physical contact

Incident involved only student offenders

Incident involved threats via social media

Required

Was the incident... *

directly observed by you

the result of an investigation of a written or oral complaint brought to you by the victim and/or a witness

Required

Tonawanda Dignity Act Coordinators

District:
Mary Beth Scullion, assistant superintendent for curriculum & instruction - 694-7688

Middle/High School:
Kristine Strible, middle school principal - 694-7660
Lyndsey Todaro, high school principal - 694-7670

Elementary Schools:
Robert Ross, Mullen principal - 694-6805
Marie Burger, Mullen/Riverview social worker - 694-6805

**NOTE: False reporting of an incident is against state law and school policy 7311. Section 240.50 of the New York State Penal Law states: A person is guilty of falsely reporting an incident when, knowing the information reported, conveyed or circulated to be false or baseless, he/she initiates a false report or warning of an alleged occurrence or impending occurrence of a crime, catastrophe or emergency under circumstances in which it is not unlikely that public alarm or inconvenience will result. This is a Class A Misdemeanor.

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