DASA Incident Reporting Form
Please fill out this electronic form to report any incidents or concerns regarding bullying, harassment or discrimination. This form can be automatically submitted to the Eldred Central School District by clicking the "Submit Form" button at the bottom of the page.

The accused individual will not be shown this report. This is a CONFIDENTIAL report and due to privacy laws, you will likely not be notified of the outcome of the school district's investigation.
Your name (this will help us to investigate the incident)
Your email (providing a contact will enable us to secure additional information, if needed.)
You are? (check appropriate box - required) *
Comments
Date of complaint(required) *
Today's Date(required) *
MM
/
DD
/
YYYY
Time of incident(s) (choose all that apply - required) *
Required
Detail of the time of incidents (above)
Describe the incident(s). Choose all that apply -required *
Required
Was there types of bias involved (if known) *
Required
Describe the incident
How are you involved in the incident
Do you know the name of the person being bullied, harassed or discriminated? (required) *
Please provide name if know:
Please provide who was involved:
Please provide name of any witnesses, if any were adults what did they do?
What school does the person being bullied, harassed or discriminated attend?
Clear selection
Was the student absent from school as a result of the incident?
Is the situation still occurring? If yes, how.
Please share any additional information or comments here:
Submit
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