DASA Incident Reporting Form
Use this to report Bullying, Harassment, or Intimidation to LCS Administration. You can also contact any school administrator, the Dignity Act Coordinator, counselor, or other staff member.

If you are having trouble submitting this form, please contact: 
Dignity Act Coordinator:   Deborah Wilkinson         315-649-2417
Building Principal:              Emily Burker                    315-649-2417
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Name of person reporting the incident
Role of person reporting incident (check one) *
Phone Number
Email Address
Name of target: (student being bullied, harassed, or discriminated against) *
Name(s) of alleged offender(s) (if unknown, please provide a description of the offender) *
Date(s) and time(s) of the incident(s)
(Be as specific as possible)
 *
Where did the incident happen? (Check all that apply) *
Required
Type of incident (Check all that apply) *
Required
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 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)
 *
Required
Names of others who may have witnessed the incident: *
Does the situation continue to occur? *
What do you think should be done about the situation? *
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