Calkins Road Incident Reporting Form

 
 
  

 
 

Incident Reporting Form

The Pittsford Central School District provides a reporting process for students, staff and parents/guardians to report concerns which will be investigated and addressed by the District. Please use this form to report any of the following allegations:

  • discrimination, by employees or students on school property or at a school function, including but not limited to such conduct based on a student’s actual or perceived race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender (defined to include gender identity or expression), or sex;
  • harassment and bullying incidents, including cyberbullying; and/or,
  • threats to students, staff or the school (such as thoughts of self-harm or suicide, violence, weapons, drugs/alcohol and theft). Call 911 first, then complete this form or call your school.

Please contact the school Dignity Act Coordinator, school principal or counselor for additional assistance or information at any time. Once an incident is reported, an administrator will investigate and respond to each allegation in the context of the Dignity for All Students Act (DASA) and the District’s Code of Conduct. All complaints will be treated in a confidential manner. You may choose to report this information anonymously. However, anonymous reports may limit the District’s ability to fully investigate and respond to the complaint.

Please note that false reporting of incidents will result in disciplinary consequences.


   
1.
*
(mm/dd/yyyy)
 
   
2.
 
   
3.
 
   
4.
 
   
5.
 




   
6.
 
   
7.
 


   
8.
 
   
9.
 
   
10.
 



   
11.
 
   
12.
 
   
13.
 





   
14.
 
   
15.
 
  
  
  
  
  
  
   
16.
 
   
17.
 
   
18.
 


   
19.
 
   
20.
 


   
21.
 
   
 
 
 
 Done  Cancel