NYS Dignity for All Students Act (DASA) Complaint Form

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NYS Dignity for All Students Act (DASA) Complaint Form - Hewlett High School

This form is to report incidents of harassment, bullying, and/or discrimination under the Dignity for All Students Act.

You can contact the school administrator, Dignity Act Coordinator, counselor, or other staff member (whoever you are most comfortable with) for information or assistance at any time.

Today's date *

YYYY

School Name where the incident occurred *

Name of person reporting incident *

Role of person reporting incident *

Student target

Student (witness)

Parent/Guardian

Staff member

Other

Your Phone Number *

Your Email Address *

Name of target (student being bullied, harassed, or discriminated against): *

Date of incident being reported *

YYYY

Time(s) of Incident(s) (approximate)

Time

Name(s) of alleged offender(s): *

What was your involvement in the incident? *

I was directly involved in the incident

I observed the incident

I heard about the incident

Where did the incident happen? Check all that apply *

On school property

Cafeteria

On a school bus

Classroom

Gym

Off school property

Hallway

Locker Room

Electronic Communication

Bathroom

At a school function

Other:

Required

Type of incident (Check all that apply) *

Physical contact (kicking, punching, spitting, tripping, pushing, taking 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)

Other:

Required

Who was involved in the incident? *

Student

Employee

Both student and employee

Required

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

If there were any adults in the area when this happened, what did they do?

Types of bias involved (if known): (Check all that apply)

Actual or perceived race

Color

National origin

Ethnic group

Religion

Religious practice

Disability

Sexual orientation

Gender (including gender identity and expression)

Sex

Other (please specify in description)

What actions, if any, have been taken by school staff regarding this incident so far?

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

Yes

If yes, how many days was the student absent?

Does the situation continue to occur? *

Yes

What do you think should be done about the situation? *

Submit

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