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.
Name of person reporting incident
Person reporting incident (check one):
Name of target (student being bullied, harassed of discriminated against):
School target attending:
Shaw Avenue School
Clear Stream Avenue School
Forest Road School
Relationship to target:
Name(s) of alleged offender(s):
Date(s) and time(s) of the incident(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
On a school bus
Off School property
The incident involved (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)
If you checked "Other" above, please describe what the incident involved.
The incident involved:
Both student and school employee
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.
Type of bias involved, if known (check all that apply):
Name of witness, if any:
Was this student absent from school as a result of the incident?
If the student was absent, please enter the number of days absent.
Does the situation continue to occur?
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