Cuba-Rushford Central School District

1) What category is this ALERT?

Please see ALERT definitions below.

(DASA) Dignity for All Students

Safety Concern

Other

2) If you choose DASA-

Incident of Discrimination

Harassment

Bullying/Cyberbullying

Report Information

4) Date of Report:

5) Name of person reporting (optional):

6) Name of victim(s)(or description:

7) Name of offender(s)(or description):

8) Location of concern:

9) Description of concern (please include as much information possible so that the administrative team can address the problem properly and be able to follow-up with you):

10) Date and time concern occurred:

11) Action(s) taken by reporter:

13) If chose other in question 12, what was the bias?

14) Would you like us to contact you regarding this issue?

Yes

No

Contact Info

15) Please enter your phone number (xxx-xxx-xxxx):

16) Please enter your email address:

Cuba-Rushford Central School District

District

Board of Ed.

Departments

Parents/Alumni

School Links

CRCS ALERT Reporting Form