New Dawn Charter High School Bullying Incident Form
New Dawn Charter High School is committed to providing a safe environment to all members of our community.
Despite our best intentions, incidents between students do occur at times. If you wish to report an incident, complete this form and return it to the building Dignity Act Coordinator. Feel free to contact the Dignity Act Coordinator for
additional information or assistance at any time. This form can be completed anonymously by omitting the signature and name. Every reported act of bullying will be investigated. Parents of targets and aggressors will be contacted in cases of confirmed bullying.

Bullying (defined): “Bullying” is a form of harassment that consists of inappropriate and often persistent behavior including threats or intimidation of others, treating others cruelly, terrorizing, coercing, or habitual put-downs and or badgering of others. Bullying occurs when someone purposely says or does mean or hurtful things to another person who has a hard time defending oneself or is in an otherwise vulnerable position.

Email address *
Person Reporting (if known):
Please check "Anonymous" if you do not wish to provide your name and information and proceed with the report. Otherwise, provide your name and contact information below. This information will only be available to school officials that are conducting the investigation.
Name
Your answer
Phone Number
Your answer
E-mail (if preferred method of communication):
Your answer
Person Reporting Incident: Check the box that applies: *
Required
How was the report received? *
Required
Date of Report *
MM
/
DD
/
YYYY
Date/Time of Incident *
Time
:
Name of Student Targeted *
Your answer
Age *
Your answer
Grade *
Your answer
School *
Name(s) of Alleged Aggressor(s) (if known): *
Your answer
Age
Your answer
Grade
Your answer
School
Your answer
Name of Witness(es) (if known): *
Your answer
Location of Bullying Incident *
Location of Bullying Incident Continued: Exact Location
Your answer
What best describes the form of bullying that took place?: *
Required
What best describes the form of bullying that took place?: If other, please provide additional information *
Your answer
Did physical injury result from this incident? *
If injured, please briefly describe
Your answer
What did the aggressor do or say? *
Your answer
Have there been similar bullying incidents involving the aggressor and the student in the past? *
If yes, briefly describe
Your answer
If bullying involved electronic communication, is documentation available?
If yes, what was the form of communication?:
Your answer
Was personal property stolen or damaged as a result of this incident?:
If property was stolen or damaged, please list items below:
Your answer
Is there any additional information that you would like to provide?
Your answer
Signature of Reporting Person
Your answer
Date *
MM
/
DD
/
YYYY
Administrative Action Taken (To be filled out by DASA Coordinator):
Your answer
Date
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service