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Dignity Act Incident Report Form
Instruction: Complete this form and hit submit. A copy will be sent to you and to a DASA coordinator and Administrator. You will receive a copy of your request via email. NOTE: Retaliation or threats of retaliation against any person involved in an investigation or harassment, bullying or discrimination will not be tolerated. If you believe that you have been subjected to such action as a result of your cooperation, please contact the building Dignity Act Coordinator or an administrator.
Email address *
Name of Reporter *
Your answer
Date of Report *
MM
/
DD
/
YYYY
What your relationship to the student on whose behalf you are reporting? *
Name of student subjected to harassment/bullying/discrimination (Target) *
Your answer
Grade level of Target *
Name(s) of alleged perpetrator(s) of harassment/bullying/discrimination (Suspect) *
Your answer
Grade and/or Age of Suspect(s) *
Your answer
School of Suspect *
Date and time of Incident (If you do not know exact date, give an approximation of any dates and times you know). *
Your answer
What was your involvement in the incident(s)? (Check all that apply.) *
Required
List any witnesses. *
Your answer
Check where the incident(s) or unwanted behaviors have occurred and/or have been observed. (Check all that apply) *
Required
Check all of the types of incidents that the target has experienced: *
Required
The behaviors are suspected of being based upon the following characteristics (actual or perceived) of the target (check all that apply). *
Required
Describe the specific nature of the incident. What happened? (Be as specific as possible). If not included above, identify the date, time and place of the behavior(s)/incident(s). If there are copies of text messages, emails, posts, etc, please submit any copies to a building administrator. *
Your answer
If there were any adults present, do you think that they were aware of the incident? If so, who were they and what did they do? *
Your answer
Was the target absent from school or did he/she avoid the setting as a result of the incident? If yes, briefly explain. *
Your answer
Does the situation continue to occur? *
To your knowledge, has anyone said anything to the suspect(s) to stop or deter the behavior? Briefly explain. *
Your answer
Has anyone reported the incident(s) to another individual? If so, who is this individual? *
Your answer
By completing this form and writing my full name on the line below, I hereby attest that all information on this document is accurate to the best of my knowledge. *
Your answer
A copy of your responses will be emailed to the address you provided.
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