Bully Reporting Form

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“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]).

  Select Date
Please list your contact information   
Offender 1   
Offender 2   
Offender 3   
Offender 4   
Offender 5   
Witness 1   
Witness 2   
Witness 3   
Where & When   
Type of bias is based on the person's actual or perceived (please check all that apply)

Check all that apply
  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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