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Elementary School DASA Form


The Phelps-Clifton Springs Central School District Board of Education is committed to providing a safe and orderly school environment where students may receive and district personnel may deliver quality educational services without disruption or interference. Responsible behavior by students, teachers, other district personnel, parents and other visitors is essential to achieving this goal. 

Harassment/bullying means the creation of a hostile environment by conduct or by threats, intimidation or abuse, including cyberbullying that:

a) has or would have the effect of unreasonably and substantially interfering with a student’s educational performance, opportunities or benefits, or mental, emotional or physical well-being; or

b) reasonably causes or would reasonably be expected to cause a student to fear for his or her physical safety; or

c) reasonably causes or would reasonably be expected to cause physical injury or emotional harm to a student; or

d) occurs off school property and creates or would foreseeably create a risk of substantial disruption within the school environment, where it is foreseeable that the conduct, threats, intimidation or abuse might reach school property. For purposes of this definition, the term "threats, intimidation or abuse" shall include verbal and non-verbal actions. 

To report any issue of harassment/bullying, please complete the form below which will be sent to your school's building administrator(s) upon completion for appropriate action. 

Name (optional)
First Name
Last Name
(555) 555-5555 format
Which category best describes you?

Incident Details

Must contain a date in M/D/YYYY format
Please include full name(s).
Name(s) of alleged offender(s), if known.
First Name
Last Name
Is the alleged offender(s) a ...required
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