Tonawanda CSD Bully Reporting Form
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 *
MM
/
DD
/
YYYY
Complainant Name *
Complainant Home/Cell Phone *
Please include area code and do not include parentheses or dashes.
Complainant Address *
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? *
Date and Approximate Time of Incident *
MM
/
DD
/
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).
Required
Description of the Incident *
Check all that apply.
Required
Was the incident... *
Required
Tonawanda Dignity Act Coordinators
District:
Mary Beth Scullion, assistant superintendent for curriculum & instruction - 694-7688

Middle/High School:
Michael Brown, high school principal - 694-7670
Lyndsey Todaro, high school assistant principal - 694-7670
David Sellan, middle school principal - 694-7660

Elementary Schools:
Robert Ross, Mullen principal - 694-6805
Claudia Panaro, Riverview principal - 694-7697
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.
Submit
Never submit passwords through Google Forms.
This form was created inside of Tonawanda City School District. Report Abuse