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Dignity for All Students Act (DASA) Bullying Report Form
Moreau DASA Form
DASA is designed to protect public schools students from bullying by employees or other students based on actual or perceived race, color, weight, national origin, ethnic group, religion, religious practice,disability, sexual orientation, gender, or sex.

The purpose of this form is to inform the District of an incident or series of incidents of discrimination or harassment(which includes bullying) so that we can investigate and take appropriate steps.

Definitions
Bullying - An unwanted, aggressive behavior that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time.

Harassment - The creation of a hostile environment by conduct or verbal threats, intimidation, or abuse that interferes with a student’s educational performance or mental, emotional or physical well-being.

Date the incident occurred.
MM
/
DD
/
YYYY
Time the incident occurred. (Please be specific.)
Time
:
Where did this incident occur?
Required
How did you find out about this?
If you were told, indicate by whom.
Your answer
What DASA category (real or perceived) do you believe this is incident is related to?
Describe what happened in as much detail as possible.
Your answer
Name of the offender (current student or staff member); if possible include both first and last names.
Your answer
Name of the victim (current student); if possible include both first and last names.
Your answer
Please list any other witnesses and include first and last names.
Your answer
Has this bullying/harassment happened to the victim before?
If the incident has happened before, have you reported it to anyone?
If you have reported this behavior before, to whom did you report? Please give first and last names.
Your answer
Your status
Please provide your first and last name.
Your answer
Please provide the best phone number where we can reach you.
Your answer
Please provide your email address.
Your answer
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