Harrisville Central School

Dignity for All Students Referral Form

This form was created so that students may report issues privately.  Paper referral forms are also available in the main office.

Person Making Report:  Date of Report:

Person making report is:         Your Relationship to Victim:

Name of Person Affected: 

Name(s) of Person(s) Involved:

Incident Date:    Time:     Place:

Incident:  (Check all that apply.)

Destroying Property                                                  Fighting/Hitting

Inappropriate Language/Profanity/Gestures               Larceny/Theft/Robbery

Intimidation/Bullying/Harassment                              Sexual Harassment/Offense

Texting/Sexting/Internet or Facebook Harassment/Etc.

Description of Incident: