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Downsville

Incident Reporting Form

Directions: The Downsville Central School District is committed to providing a safe environment to all members of our community. Despite our best intentions, incidents between students do occur at times. If you witness a disturbing incident between two or more students, complete this form and return it to the Dignity Act Coordinator (Mrs. Menke) in the guidance office. Contact the school for additional information or assistance at any time. This form can be completed anonymously by omitting signature and name. EVERY reported act of bullying will be investigated. Parents of aggressors and targets will be contacted in cases of confirmed bullying.


Date of report:
Name of student target: Age & Grade:
Name(s) of alleged aggressor(s)(if known. Age & Grade:
Names of witness(es)(if known):
Where did the incident(s) happen(choose all that apply)?





What best describes what happened(choose all the apply):









What did the alleged aggressor(s) say or do? (Include dates.)
Did a physical injury result from this incident?


Name of person reporting incident (OPTIONAL):
Action Taken by Adult Reporting:

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

2 + 9 =
14784 State Hwy 30 Downsville, NY 13755
P 607.363.2100
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