Bully Incident Report
Upon receipt of this digital alert form a formal investigation will take place or occur. More information will be collected as outlined and required through the Dignity for All Students Act (DASA).
http://www.p12.nysed.gov/dignityact/
Today's Date *
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Date of Incident *
MM
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Role of person reporting the incident *
What was your involvement in the incident?
Where did this incident take place? *
Your answer
Names of people involved and their role (witness, victim, or participant). *
Your answer
Description of incident *
Your answer
If there were any adults in the area when this happened, please indicate who and what they did.
Your answer
Name(s) of others who may have witnessed the incident:
Your answer
Is this a reoccurring situation? *
Your name (optional)
Your answer
Grade of Target (optional)
Your answer
Phone number or email you can be reached (optional)
Your answer
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