DeRuyter CSD

Bullying Report Form

Please fill out this electronic form to report any incidents or concerns regarding bullying or harassment. This form can be automatically submitted to the DeRuyter Central School District by clicking on the "Submit Form" button at the bottom of the page.

Bolded questions must be answered to submit the form.

The accused student or staff member will not be shown in this report. Due to privacy laws, you likely will not be notified of the outcome of the school district's investigation.

1. Date of complaint:
2. Date of incident:
3. Time of incident:

4. Place of incident:
5. Describe the incident:
6. What is the sex of the student being bullied?

7. Do you know the name of the person being bullied?

Please provide the name if known:
8. What is the sex of the student doing the bullying?

9. Do you know the name of the person doing the bullying or harassment?

Please provide the name(s) if known:
10. Please provide the names of any witnesses:
11. What school does the person being bullied attend?

12. Your name (optional)
13. Your email (optional)

Thank you for helping us to create a school climate where all students feel safe and secure.