Dignity for All Students Act (DASA) Report Form

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This form is to be used to report an incident of bullying, harassment, discrimination, or cyberbullying. Includes, but is not limited to, those acts based on a person’s actual or perceived:

Race
Color
Weight
National Origin
Ethnic Group
Religion
Religious Practice
Disability
Sexual orientation
Gender (including gender identity or orientation)
Sex

The questions and prompts inthis form will be used to initiate an investgation into the event and to develop a plan for response. If you have any questions about completing this form, please contact Katie Cannon, Dignity Act Coordinator, email: kcannon@margaretvillecs.org, phone 845-586-2647 ext 1028.

Name of target, first and last, NO INITIALS: (student being bullied, harassed, or discriminated against) *

Name(s) of alleged offender(s), first and last, NO INITIALS :
*

Date(s) and time(s) of incident:
*

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

Classroom

Gym

Locker Room

Hallway

Bathroom

Cafeteria

On a school bus

At a school function, e.g. sporting event or field trip

Off school property, i.e., cyber offense

Electronic Communication, e.g., text message, social media

Other:

Required

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:

Required

Describe the specific nature of the incident. What happened? (Be as specific as possible). What did the alleged offender say or do? Send any copies of text messages, emails, etc. if possible to jholden@margaretvillecs.org with "DASA Report" as the subject.
*

Type of bias involved (if known): (Check all that apply)
*

Not sure

Race

Color

Weight

National Origin

Ethnic Group

Religion

Religious Practice

Disability

Sexual orientation

Gender (including gender identity or orientation)

Sex

Other:

Required

Names of others who may have witnessed the incident:
*

Contact information for the person making this report. This information will be used during the investigation to confirm report receipt, clarify report details, and communicate report outcomes.

Person reporting the incident, completing this form:

Role of the person reporting the incident:

Student (target)

Student (witness)

Parent/Guardian

Faculty/Staff Member

Other:

Clear selection

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