Report An Incident

Afton CSD - DASA Incident Reporting

I have read and understand the confidentiality statement.
Today's Date:
Name of person reporting (optional):
Role of person reporting (check one)

Phone Number:
Email Address:
Name of target (student being bullied, harassed, or discriminated against):
Name of alleged offenders(s):
Date(s) and time(s) of incidents(s):
What was your involvement in the incident?
Where did the incident(s) happen (choose all that apply)?

Type of incident (check all that apply)?

Other (describe):
Who was involved in the incident?

Describe the specific nature of the incident. What happened? (Be as specific as possible). What did the alleged offender(s) say or do? Include any copies of text messages, emails, etc. if possible.
If there were any adults in the area when this happened, what did they do?
Types of bias involved (if known): (check all that apply)

Other (describe)
Names of others who may have witnessed the incident:
Was the student absent from school as a result of the incident?
Number of days student was absent:
Does the situation continue to occur?
What do you think should be done about the situation?

To validate your submission, please answer the following math problem:

captcha math problem
© 2021. 29 Academy Street, P.O. Box 5   •   Afton, NY 13730   •   P 607.639.8200   •   F 607.639.1801
View text-based website