Dignity Act/Incident Form
The purpose of this form is to inform the District of an incident or series of incidents, so that the District can investigate and take appropriate action.
Email address
Your answer
1. Your Name (Please type your first and last name)
Your answer
2. Person filling out this form
3. Today's Date
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4. Phone Number
Your answer
5. Date of alleged incident
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6. Were there any witnesses?
7. If yes, list the name(s) of the witness(es).
Your answer
8. Where did the incident(s) take place? (i.e. hallway near pool, social media, bus, etc.)
Your answer
9. Describe the incident. (Please use as many details as possible)
Your answer
10. What supporting documentation (i.e., copies of emails, notes, photos, etc.) do you have related to this incident? Please list these items below and save a copy for the Main Office.
Your answer
11. Has the incident been previously reported?
12. If yes, when and to whom did you report this incident?
Your answer
13. Do you believe that this incident was bullying, harassment, or discrimination?
14. I certify that all of the information that I provided on this form is true and accurate.
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