Dignity for All Students Act (DASA)
Dignity for All Students Act (DASA)
Reporting Form

This form may be completed by parents, students or staff and must be filled out in its entirety. The following terms are defined by the Renaissance Charter High School Code of Conduct and should be used to guide allegations of bullying, harassment, or discrimination.* Please note that all reported incidents may not fall under the Dignity For All Students Act but will be addressed as per the Renaissance Charter High School discipline policies and procedures at the discretion of the building principal. All incidents, reports, and investigations are classified as confidential.
Bullying, harassment, and discrimination under DASA is defined as the creation of a hostile environment by conduct, verbal threats, intimidation or abuse related to the 11 protected classes that would have the effect of substantially interfering with a student’s educational performance, opportunities, or mental, emotional or physical well- being

Email address *
Name of reporter
Your answer
Role (ie. Teacher, parent, student)
Your answer
Date of Incident
MM
/
DD
/
YYYY
Time of Incident
Time
:
Place of Incident:
Your answer
Name of person(s) allegedly being discriminated against
Your answer
Name of person(s) allegedly committing the discrimination
Your answer
Description of incident:
Your answer
Name(s) of witnesses
Your answer
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