DASA incident reporting form
Valley Stream School District 30 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 school administrator. Or, you can complete this form and return it to the school administrator or Dignity Act Coordinator, Nicole Schimpf. Administration will review and respond to each incident in the context of the student Code of Conduct.
*All complaints will be treated in a confidential matter. Anonymous reports may limit the district’s ability to respond to the complaint.
**False reporting of incidents may result in disciplinary consequences and may be reported to an appropriate law enforcement agency.
Today's date *
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Name of person reporting incident
Optional
Your answer
Person reporting incident (check one): *
Phone *
Your answer
Email *
Your answer
Name of target (student being bullied, harassed of discriminated against): *
Your answer
School target attending: *
Relationship to target: *
Name(s) of alleged offender(s): *
Your answer
Date(s) and time(s) of the incident(s) *
Your answer
What was your involvement in the incident? *
Where did the incident happen? (check all that apply) *
Required
The incident involved (check all that apply): *
Required
If you checked "Other" above, please describe what the incident involved.
Your answer
The incident involved: *
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, email, etc, if possible. *
Your answer
Type of bias involved, if known (check all that apply): *
Required
Name of witness, if any:
Your answer
Was this student absent from school as a result of the incident? *
If the student was absent, please enter the number of days absent.
Your answer
Does the situation continue to occur? *
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This form was created inside of Valley Stream UFSD 30.