DASA Reporting Form
The Dignity Act was signed into NYS law on September 13, 2010 and took effect on July 1, 2012. The Dignity for All Students Act (The Dignity Act) seeks to provide the State’s public elementary and secondary school students with a safe and supportive environment free from discrimination, intimidation, taunting, harassment, and bullying on school property, a school bus and/or at a school function.This form exists to support students, staff, or anyone else in reporting instance which may violate the Dignity Act.
Any reporting via this form is anonymous (although you may leave your name if you choose). Only answer questions on this form that you are able to. If you provide your name on the form, you may be contacted.
What is your name?
What is your location?
Jr/Sr High School
What is your contact telephone number?
Who is the victim?
What is your relationship to the victim?
Name or description of the alleged offender?
Detailed description of the incident(s)?
Location of incident(s)?
Date & time (approx) of incident(s)?
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This form was created inside of Herkimer Central School District.