Dignity for All Students Act: Report Form
This form can be completed by anyone who is concerned about an incident.
This form MUST be filled out by any staff member who has been made aware of an incident (s).
Please fill out this form with as much information as possible and submit it within 24 hours of the incident.

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Email *
Date the report is being filled out: *
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DD
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Name of person filing the report: *
Identification of person filling out this form: *
Required
The best way to reach me: *
Identify the Alleged Victim (name & grade): *
Identify the Alleged Offender(s): List the name os student(s) or adult(s) who are being accused or unknown: *
I would best describe the incident(s) s related to the students: check all that apply *
Required
The incident(s) have occurred in the following location(s):
The incident(s) has/have involved the following: check all that apply *
Required
Please describe the incident: Describe what was said and/or done and by whom, be specific and give as much detail as possible of the incident. (Specific details of what you witnessed; exactly what you saw and heard. *
Is this the first time this incident has happened? *
Date and Time of Incident(s): *
Other Witnesses: Please identify any other people who may have witnessed the incident(s), please identify if it is a student or adult. *
Have you reported this situation to anyone else before filing this report? *
If yes, to whom? and when? *
Was medical treatment needed by anyone involved in this situation? *
A copy of your responses will be emailed to the address you provided.
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