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Incident Reporting Form
Dignity for All Students Act: Form to be completed by person reporting the incident (for person receiving the complaint and/or investigating the incident and submitted to the Dignity Act Coordinator (DAC).
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* Indicates required question
School
*
Brookside Elementary School
Donnelly Elementary School
RTS Middle School
HIgh School
Other
Today's Date
*
MM
/
DD
/
YYYY
Name and position of person reporting the incident
*
Your answer
Role of person reporting incident (check one)
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Anonymous
Student Target
Student Witness
Parent/Guardian
Staff Member
Other
Phone number
Your answer
Email address
Your answer
Name of target: (student being bullied, harrassed, or discriminated against)
*
Your answer
Name (s) of alleged offender (s):
*
Your answer
Date and Time of Incident
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Your answer
What was your involvement in the incident?
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I was directly involved in the incident
I observed the incident
I heard about the incident
Required
Where did the incident happen? (Check all that apply
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On school property
Classroom
Cafeteria
Gym
On a school bus
Off school property
Hallway
Locker room
Bathroom
At a school function
Electronic Communication
Other (if other please describe below)
Required
If you choose other for where the incident happen, please describe:
Your answer
Type of incident (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 rumours, soical exlusion, intimidation)
Abuse (actions or statements that put an indivudal in fear of bodily harm)
Cyberbulllying (misusing technology/social media to harrass, tease, threathen, post pictures
Other
Required
If you choose other for type of incident, please describe
Your answer
Who was involved in the incident? (Check all that apply)
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Student
Employee
Other
Required
Describe the specific nature of the incident. What happened? (Be as specific as possible). What did the alleged offender say or do? If needed, you may be asked for text messages, emails, etc.
*
Your answer
If there were any adults in the area when this happened, what did they do
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Your answer
Type of bias involved (if known): check all that apply
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Race
Religion
Sex
Color
Religious practice
Weight/Size
Disability
National origin
Sexual orientation
Ethnic group
Gender
Other
Required
If you chose other for type of bias, please describe.
Your answer
Name(s) of others who may have witnessed the incident:
*
Your answer
Was the student absent of from school as a result of the incident?
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No
Yes
Unsure
Describe the impact this incident has had on the student (target):
*
Your answer
Does the situation continue to occur?
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Yes
No
What do you think should be done about the situation?
*
Your answer
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