Arkport Central School District

1) Today's Date:

2) Role of person reporting the incident:

Faculty/Staff Member

The Parent/Guardian To The Alleged Victim

Alleged Victim

Anonymous Report (Skip Questions 3 and 4)

Other

3) Contact Email: (optional)

4) Contact Phone Number: (optional)

5) Name of Student:

(student being bullied, harassed, or discriminated against)

6) Student Grade:

(student being bullied, harassed, or discriminated against)

7) Name of alleged offender (#1):

Please indicate if the offender (#1) was a student, faculty, or staff member.

8) Name of alleged offender (#2): (optional)

Please indicate if the offender (#2) was a student, faculty, or staff member.

9) Name of alleged offender (#3): (optional)

Please indicate if the offender (#3) was a student, faculty, or staff member.

10) Date of Incident:

11) Time of Incident:

12) What was your role in the incident?

I was directly involved in the incident.

I observed the incident.

I heard about the incident.

13) The incident occurred in the following location:

(check all that apply)

14) I would best describe the incident(s) as related to the student:

(check all that apply)

15) 14. The incident(s)has/have involved the following:

(check all that apply)

Physical (direct) - hitting, punching, tripping, kicking, pushing, scratching, ganging up, extortion

Social/Relational (direct or indirect)- excluding or threatening to exclude, spreading rumors/gossip

Verbal (direct) - name-calling, teasing, intimidating, threatening, taunting, making offensive or di

Cyberbullying - sending insulting messages or threats by email, text messaging, on social media, cha

16) Please describe the incident:

Describe what was said and/or done and by whom.

17) Attach any evidence for a description of the incident if applicable. (optional)

Max 10 files | 200 MB limit

18) Is this the first time this has happened.

Yes

No

Unsure

19) Does the situation continue to occur?

Yes

No

20) Other Witnesses:

Please identify any other people who may have witnessed the incident(s). Please indicate if they were a student or adult.

21) Have you reported this situation to anyone else before filing this complaint?

If yes, please identify who you reported the situation to and on what date.

22) Was medical treatment needed by anyone involved in this situation?

Yes

No

I don't know

Arkport Central School District

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