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
| Name of target student: | |
| Gender: | Male Female |
| School attending: | |
| Date of incident: | (mm/dd/yyyy) |
| Time of incident: | |
| This report is being made due to a(n): (may select multiple choices) | 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: |
| Other information for above question as needed: | |
| Basis of complaint / grievance: (may select multiple choices) | Race Religion Gender Ethnic Group Religious Practice National Origin Sex Disability Sexual Orientation Color Weight Other/not sure (please briefly explain below): |
| Explain other from above: | |
| Name of offending person (s), grade and gender: | |
| Incident is a result of: (may select multiple choices) | Student Employee conduct |
| Description of alleged harassment/bullying/discrimination incident(s): | |
| The incident(s) involved: (may select multiple choices) | Physical (direct)- hitting; punching; tripping; kicking; pushing; scratching; ganging up; extortion; damaging property Social/Relational (direct or indirect)- excluding or threatening to exclude; spreading rumors/gossiping; ostracizing; alienating; using threatening looks/glances Verbal (direct)- name calling; teasing; intimidating; threatening; taunting; making offensive or discriminatory remarks (rude and or lewd) Cyberbullying- sending insulting messages or threats by email, text messaging on social media, chat rooms, etc. Other |
| Witnesses, if any, or others with knowledge or information important to this investigationm, including contact information for each: | |
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