JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
DASA Incident Reporting Form
To be completed by person reporting the incident. You can contact the school administrator, Dignity Act Coordinator (Janelle Baker), counselor, or other staff member (whoever you are most comfortable with) for information or assistance at any time.
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Role of the person reporting (check one)
*
Student Target
Student (witness)
Parent/Guardian
Staff Member
Other
Phone Number
*
Your answer
Email
*
Your answer
Name of target: (student being bullied, harassed, or discriminated against)
*
Your answer
Name(s) of alleged offender(s):
*
Your answer
Date(s) and time(s) of incident:
*
Your answer
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
Cafeteria
On a school bus
Classroom
Off school property
Gym
Hallway
Electronic Communication
Locker Room
Bathroom
At a school fucntion
Other (describe below)
Required
If you selected other- please explain here
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 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 (sexting))
Other (describe below)
Required
If you selected other- please explain here
Your answer
Who was involved in the incident?
*
Student
Employee
Both student and 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, emails, etc. if possible.
*
Your answer
If there were any adults in the area when this happened, what did they do?
*
Your answer
Types of bias involved (if known): (Check all that apply)
*
Race
Religion
Sex
Color
Religious Practice
Weight/size
Disability
National origin
Sexual orientation
Ethnic group
Gender
Other (describe below)
Required
If you selected other- please explain here
Your answer
Names of others who may have witnessed the incident:
*
Your answer
Was the student absent from school as a result of the incident?
*
no
yes (if yes, complete the next question)
If yes, how many days were they absent?
Your answer
Does the situation continue to occur?
*
Yes
No
What do you think should be done about the situation?
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Byron-Bergen Central Schools.
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report
