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.
Sign in to Google to save your progress. Learn more
Your name (optional)
Person reporting incident (check one)
 Your phone number
Today's date *
MM
/
DD
/
YYYY
4.  Date of incident(s) *
5.  Time of incident(s) *
Required
6.  Place of incident(s) *
Comment Box:
7.  Describe the incident(s) *
Do you know the name of the victim? *
Please provide name if known
Do you know the name of the offender? *
Please provide name(s) if known
12.  Please provide the names of any witnesses.  (If there are no witnesses, please indicate "none.") *
13.  What school does the person being bullied attend? *
Thank you for helping us to create a school climate where all students feel safe and secure.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Adirondack Central School District.

Does this form look suspicious? Report

Google Forms