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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 Remsen Central School District by clicking on the "Submit Form" button at the bottom of the page. Questions with the red asterisk must be answered to submit the form. The accused student or staff member will not be shown this report. Due to privacy laws, you likely will not be notified of the outcome of the school district's investigation.

Required

Your Name
First Name
Last Name
Must contain a date in M/D/YYYY format
Time of incident(s)requiredPlease select up to 4 choices
Please select up to 4 choices
Place of Incident(s)requiredPlease select up to 8 choices
Please select up to 8 choices
What is the gender of the individual being bulled?requiredPlease select up to 1 choice
Please select up to 1 choice
Do you know the name of the person being bullied?requiredPlease select up to 1 choice
Please select up to 1 choice
What is the gender of the person bullying?requiredPlease select up to 1 choice
Please select up to 1 choice
What school does the person being bullied attend?requiredPlease select up to 1 choice
Please select up to 1 choice