Adirondack Central School District DASA Incident Report Form
Adirondack Central School District is committed to providing a safe, supportive environment free from harassment, bullying or discrimination. The District encourages the involvement of staff, students, parents and community members in the implementation and reinforcement of the Dignity for All Students Act (DASA). If you believe you, or someone else, has been the target of harassment, bullying - including cyber bullying - or discrimination, please use this form to report all allegations.
Please fill out this electronic form to report any incidents or concerns regarding bullying or harassment. This form can be automatically submitted to the Adirondack Central School District by clicking on the "Submit Form" button on the bottom of the page.
Questions with an ( * ) must be answered to submit the form. All complaints will be treated in a confidential manner. Anonymous reports may limit the District's ability to respond to the complaint.
The accused student or staff member will not be shown this report. False reporting of incidents may results in disciplinary consequences and may be reported to a law enforcement agency.
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* Required
Your name (optional)
Your answer
Person reporting incident (check one)
Student
Student - witness
Parent/Guardian
Staff Member
Other:
Your phone number
Your answer
Today's date
*
MM
/
DD
/
YYYY
4. Date of incident(s)
*
Your answer
5. Time of incident(s)
*
Before school
During school
After school
Required
6. Place of incident(s)
*
Choose
Bus (Please provide bus number, animal or driver name in comment box)
Cafeteria
Hallways
At locker
Bathroom
Classroom (Please provide class name in comment box)
Playground
Outside of school
Phone (calls or text)
Internet (social media)
Comment Box:
Your answer
7. Describe the incident(s)
*
Your answer
Do you know the name of the victim?
*
Yes
No
Please provide name if known
Your answer
Do you know the name of the offender?
*
Yes
No
Please provide name(s) if known
Your answer
12. Please provide the names of any witnesses. (If there are no witnesses, please indicate "none.")
*
Your answer
13. What school does the person being bullied attend?
*
Adirondack High School
Adirondack Middle School
Boonville Elementary School
West Leyden Elementary School
Thank you for helping us to create a school climate where all students feel safe and secure.
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