Persell Middle School DASA Reporting Form
The Jamestown City School District is committed to providing a safe, supportive environment free from harassment, bullying or discrimination. The District encourages the involvement of staff, students, parents and community members in the implementation and reinforcement of the Dignity for All Students Act (DASA).

If you believe that a student has been the target of harassment, bullying—including cyberbullying—or discrimination, please use this form to report all allegations. School or district personnel who witness an incident or receive a report of an incident must immediately notify the principal, superintendent or designee, and must complete and submit this written report within two (2) days.

All complaints will be treated in a confidential manner. Anonymous reports may limit the district’s ability to respond to the complaint. A prompt and thorough investigation will be conducted for all incident reports.

Please provide as much information as possible about the incident so that the school administrator can follow up as needed to determine the appropriate response under the District Code of Conduct.

What is the name of the student who was the target of bullying, harassment, or discrimination?
Your answer
What is the grade level of this student?
Where did the incident happen?
Your answer
When did the incident happen? (date/time if known)
Your answer
Please provide the name(s) of the person(s) accused of bullying, harassment, or discrimination, if known.
Your answer
Please describe the incident as completely as possible.
Your answer
Please provide the name(s) of any witnesses who may have observed the incident.
Your answer
What is your relationship to the student(s)?
If you are willing to provide your name, please do so. This report will be kept confidential.
Your answer
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