CCS DASA Incident Reporting Form
Please use this form to report an incident of bullying, harassment or discrimination. The form will be anonymous, unless you include your name as the reporter. The completed form will be submitted to the building principal for investigation and, if appropriate, corrective action. If there is an immediate threat, or you fear a student is unsafe, speak with the building principal immediately, then complete the form.
Student Victim's Name
Grade of Victim
Date of Incident
Approximate Time of Incident
Location of Incident
Did you witness the incident?
If you were not a witness, how was it reported it to you?
Describe the incident. Be as specific as possible about what occurred. For example, if profanity was used, please state the actual profane words used; if a threat was made, please state what the aggressor said, etc...
Name(s) of the individual(s) accused of discrimination, harassment or bullying:
Other possible victims:
Were there any witnesses/bystanders to the incident?
If yes, please identify those witnesses and/or bystanders:
Which of the following best indicates the basis of the alleged bullying, harassment and/or discrimination? (Check all that apply):
Which of the following best describes where the incident occurred? (Check all that apply):
On school property
At a school-sponsored function off school grounds
On the School Bus
Which of the following best indicate(s) the type of incident that occurred?
Intimidation of abuse, but no verbal threat or physical contact
Verbal threat, but no physical contact
Both verbal threat and physical contact
To your knowledge, who was involved in the incident?
Cooperstown Central School District STUDENT(S)
Cooperstown Central School District EMPLOYEE(S)
Both CCSD STUDENT(S) and EMPLOYEE(S)
What is your relationship to the student victim?
I certify that all statements on this form are accurate and true to the best of my knowledge (Enter name below or write "Anonymous")
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This form was created inside of Cooperstown Central School District.