DLL DASA Form

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DLL DASA Form

Bath Central School District is committed to providing a safe, supportive environment free from harassment, bullying or discrimination. The District encourages the involvement of staff, students, parents and community members in the implementation and reinforcement of the Dignity for All Students Act (DASA). If you believe you, or someone else, has been the target of harassment, bullying--including cyberbullying--or discrimination, please use this form to report all allegations.
You can complete this form online and it will automatically be directed to the appropriate school administrator. The administrator will review and respond to each incident in the context of the student Code of Conduct.

*All complaints will be treated in a confidential manner. Contact information must be provided for DASA coordinators to properly investigate and respond. Anonymous reports will not be addressed.
**False reporting of incidents may result in disciplinary consequences and may be reported to an appropriate law enforcement agency.

Today's date *

YYYY

Name of the person reporting the incident *

Person reporting the incident

Student

Student (Witness)

Parent/Guardian

Staff Member

Self

Other

Clear selection

Phone number

Email Address

Name of Victim

Relationship to victim

Friend

Family

Peer

Stranger

Staff

Clear selection

Name(s) of alleged offenders

Date(s) and time(s) of incident

What is your involvement in the incident

Where did the incident(s) happen (Select all that apply)?

On school property

Classroom

Hallway

Bathroom

Cafeteria

Gym

Locker Room

Library

Other

At a school function

On a school bus

Off of school property

The incident involved (Select all that apply):

Physical contact (kicking, punching, spitting, tripping pushing, taken belongings)

Verbal threats (gossip, name-calling, put-downs, teasing, being mean, taunting, making threats)

Psychological (non-verbal actions, spreading rumors, social exclusion, intimidation)

Abuse (actions or statements that put an individual in fear of bodily harm)

Cyberbullying (misusing technology/social media to harass, tease, threaten, post pictures(sexting))

The incident involved (select all that apply)

Student(s)

Employee(s)

Both Student(s) and employee(s)

Clear selection

Describe the specific nature of the incident. What happened (be specific as possible). What did the alleged offender say or do? Include any copies of text messages, emails, etc. if possible.

Types of bias involved(check all that apply)

Race

Color

Weight/size

National origin

Ethnic group

Religion

Religious practice

Disability

Sexual orientation

Gender

Sex

Other

Name of witness(es), if any:

Was the student absent from school as a result of the incident

Yes

Clear selection

If absent, please enter the number of days absent:

Submit

Clear form

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