Dignity for All Students Act (DASA) Complaint/Reporting Form
Your completed form will be sent to the building principal where the incident occurred. As a result of your submission, you will be contacted within three school days and this incident will be investigated. The outcome of the investigation will be shared with you in writing. If any further incidents occur, you will need to complete a separate incident report form. 
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Email *
Complainant Last Name *
Complainant First Name *
Complainant Phone Number (Best Contact) *
Complainant Home Address *
Location of alleged DASA Incident *
Target/Victim's Name *
Target/Victim's Grade
 *
Offender's (#1) Name *
Offender #1 (select appropriate title)
 *
Offender's (#2) Name, if applicable
Offender #2 (select appropriate title)
Offender's (#3) Name, if applicable
Offender #3 (select appropriate title)
Please identify the name(s) and contact information for any witness(es) to the incident.
Please select the type(s) of bias, actual or perceived, that the victim experienced as part of this incident (check all that apply) *
Required
Describe 'other' type of bias, actual or perceived, that the victim experienced as part of this incident
Please provide a detailed description of the incident. *
Please type in your full name as an Electronic Signature Acknowledgement attesting to the information provided in this DASA reporting form. *
Please confirm the date the information was provided in this DASA reporting form.
 *
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A copy of your responses will be emailed to the address you provided.
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