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Middle School DASA Reporting Form
A student, parent/guardian or staff member may file a complaint of harassment, discrimination, intimidation, or bullying of a student pursuant to The Dignity Act regulations and school policy. This report includes the information necessary to conduct a thorough investigation of the alleged offense and take appropriate action. You may choose to report this information anonymously. All complaints will be treated in a confidential manner. Anonymous reports may limit the school's ability to respond to the report.
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Date of the Incident *
Name of Person Reporting the Incident
Role of Person Reporting the Incident *
Phone Number
Email Address
Name of Target(s): *
Name of alleged offender(s): *
What was your involvement in the incident? *
Where did the incident take place (check all that apply): *
Type of incident (check all that apply): *
Name any others who may have witnessed the incident: *
Describe the incident. What happened? Be as specific as possible. What did the alleged offender say or do? Email any images to Mrs. Meshulam: *
If there were any adults in the area when this happened, what did they do? *
What the student (target) absent from school as a result of this incident? *
What was the type of bias (if know). Check all that apply.
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