home of the eagles

Downsville

Incident Reporting Form for Adults

For reports or complaints of sexual harassment, and harassment because of race, national origin, religion and disability. This includes all types of bullying: verbal, social exclusion or isolation, physical, spreading lies or false rumors, having money or other things taken or damaged, threatened or forced to do things, or cyber-bullying (via cell phone or the Internet)


Complainant:
Home Address:
Work Address:
Home Phone:
Work Phone:
Date of allege incident(s):
Did the incidents involve:




Name of person(s) you believe harassed you or another person:
If the alleged harassment was toward another person, identify that other person:
Describe the incident as clearly as possible, including such things as what force, if any, was used, any verbal statement (i.e. threats, requests, demands, etc.), what, if any phyical contact was involved.
When and where did the incident occur?

To validate your submission, please answer the following math problem:

6 + 1 =
14784 State Hwy 30 Downsville, NY 13755
P 607.363.2100
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