DASA Reporting Form

Below is a form that can be used to inform the District Coordinator about bullying and/or harassment you have witnessed or personally experienced 24 hours/7 days a week.  By completing and submitting the form, the DASA Coordinator will receive notification of your report and inform the School Building Administrator.

If you prefer, at the bottom of this page, you can find a printable form that you can complete and return to the school Attn:  Mr. Thomas Cervola, Dignity Act Coordinator

Below the form is the DASA Building Coordinator and corresponding contact number.
Report bullying today!

If you are not the student being allegedly harassed or bullied, we will not use your name during our investigation.  We do, however, hold the right to contact you, if the need arises.

Please fill out this form to the best of your ability.

Are you the person allegedly being teased or harassed in any way?

What time of day is this happening?  Please enter time of day, class period, etc.

Please enter your name.  This is required to avoid anonymous and possible false reports.

If you are a Gilboa-Conesville CSD student, please tell us what school you or the individual allegedly being bullied attends.

Where is this happening?  Be specific:  Playground, bus, classroom, hallway, etc.

Describe what is happening in the best way that you can.  Be as specific as you can.

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You may also contact the Dignity Act Coordinator directly.
Mr. Thomas Cervola, Principal
(607) 588-7541, Press #2