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Dignity for All Students Act (DASA) Incident Reporting Form
This form will route the school of the person reported as a target. The school administration will investigate this report.
To be completed by person reporting the incident (or the person receiving the complaint and/or investigating the incident):
Date:
*
Name of School Student Attends:
*
Walt Whitman High School
Stimson Middle School
Silas Wood
Birchwood
Maplewood
Countrywood
Oakwood
Name of person reporting incident:
*
Role of person reporting incident:
*
Student Target
Student (witness)
Parent/Guardian
Staff Member
Other
Other
Phone:
*
Email:
*
Name of target: (student being bullied, harassed, or discriminated against)
*
Name(s) of alleged offender(s):
*
Date(s) and time(s) of incident:
*
What was your involvement in the incident?
*
I was directly involved in the incident
I observed the incident
I heard about the incident
Other
Other
Where did the incident happen? (Check all that apply)
*
On school property
Cafeteria
On a school bus
Classroom
Gym
Hallway
Locker Room
Electronic Communication
Bathroom
At a school function
Off school property
Other
Other
Type of incident (Check all that apply)
*
Physical contact (kicking, punching, spitting, tripping, pushing, taking belongings)
Verbal threats (gossip, name-calling, put-downs, teasing, being mean, taunting, making
threats)
Psychological (non-verbal actions, spreading rumors, social exclusion, intimidation)
Abuse (actions or statements that put an individual in fear of bodily harm)
Cyberbullying (misuse of technology/social media to harass, tease, threaten, post pictures)
Other
Other
Who was involved in the incident?
*
Student
Employee
Both student and employee
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 when there is a section to upload.
*
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)
*
Race
Religion
Sex
Color
Religious practice
Weight/size
Disability
National origin
Sexual orientation
Ethnic group
Gender
Other
Other
Names of others who may have witnessed the incident:
*
Was the student absent from school as a result of the incident?
*
No
Yes
Number of days student was absent:
*
Does the situation continue to occur?
*
No
Yes
What do you think should be done about the situation?
*
Any Additional Comments:
*
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