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?
Your answer
What is your location?
What is your contact telephone number?
Your answer
Who is the victim?
Your answer
What is your relationship to the victim?
Name or description of the alleged offender?
Your answer
Detailed description of the incident(s)?
Your answer
Location of incident(s)?
Your answer
Date & time (approx) of incident(s)?
MM
/
DD
/
YYYY
Time
:
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