NCCS Mooers Elementary DASA Form (Dignity for All Student Act)
 DASA is designed to protect public schools students from bullying by employees or other students based on actual or perceived race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender, or sex. The purpose of this form is to inform the District of an incident or series of incidents of discrimination or harassment (which includes bullying) so that we can investigate and take appropriate steps. 

Definitions: Bullying – An unwanted, aggressive behavior that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time. 

Harassment – The creation of a hostile environment by conduct or verbal threats, intimidation, or abuse that interferes with a student’s educational performance or mental, emotional or physical well-being.  
Sign in to Google to save your progress. Learn more
When did this incident occur? *
MM
/
DD
/
YYYY
Time the incident occurred: (Be as specific as possible) *
Time
:
Where did this incident occur? *
If the incident occurred on Social Media what platform was it on?
Clear selection
How did you find out about this? *
If you were told about the incident by whom?
What DASA category (real or perceived) do you believe this incident is related to?   
 *
Describe what happened in as much detail as possible:  
 *
Name of the offender (current student or staff member); if possible include both first and last names:  
 *
Please list any other witnesses and include first and last names:  
 *
Has this bullying/harassment happened to the victim before?  
 *
If the incident has happened before, have you reported it to anyone?  
 *
If you have reported this behavior before, to whom did you report? Please give first and last names:  
  Your status:  
 *
Please provide your first and last name:  
 *
Please provide the best phone number where we can reach you:  
 *
Please provide your email address:  
 *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Northeastern Clinton Central School District.

Does this form look suspicious? Report

Google Forms