Building/District Contact List Main Phone# 607-243-5533 Elementary Contact: Elementary Principal, *7516 Junior/Senior High Contact: Junior/Senior High Principal, *7506 District Contact: Dignity Act Coordinator, *7331
Male
Female
Employee, who directly observed an incident or series of incidents. Enter Employee's name and title below:
Employee, who was made aware of an incident or series of incidents. Enter Employee's name and title below:
Parent or community member. Enter Complaint's name and relationship to targeted student below:
Other, type name, relationship to targeted student and contact information below:
Race Religion Gender
Ethnic Group Religious Practice National Origin
Sex Disability Sexual Orientation
Color Weight
Other/not sure (please briefly explain below):
Student and/or
Employee conduct
Intimidation or abuse, but no verbal threat(s) or physical contact
Verbal threat(s) but no physical contact
Physical contact but no verbal threat(s)
Verbal threat(s) and physical contact