Dignity Act Incident Report Form

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Instruction: Complete this form and hit submit. A copy will be sent to you and to a DASA coordinator and Administrator. You will receive a copy of your request via email. NOTE: Retaliation or threats of retaliation against any person involved in an investigation or harassment, bullying or discrimination will not be tolerated. If you believe that you have been subjected to such action as a result of your cooperation, please contact the building Dignity Act Coordinator or an administrator.

Email *

Name of Reporter *

Date of Report *

YYYY

What is your relationship to the student on whose behalf you are reporting? *

I am the student target.

Student (witness)

Parent/Guardian

Staff/Faculty Member

Other:

Name of student subjected to harassment/bullying/discrimination (Target) *

Grade level of Target *

Pre-K

Kindergarten

1st

2nd

Other:

Name(s) of alleged perpetrator(s) of harassment/bullying/discrimination (Suspect) *

Grade and/or Age of Suspect(s) *

School of Suspect *

Fort Montgomery Elementary School

Other:

Date and time of Incident (If you do not know exact date, give an approximation of any dates and times you know). *

What was your involvement in the incident(s)? (Check all that apply.) *

I was directly involved in the incident

I observed the incident

I heard about the incident

Required

List any witnesses. *

Check where the incident(s) or unwanted behaviors have occurred and/or have been observed. (Check all that apply) *

Cafeteria/Auditorium/Gymnasium

Bathroom

Bus

Classroom

Hallway

Library

Off campus (School-sponsored event)

Off campus (non-school-sponsored event)

Parking Lot

Playground

Recess Area

Stairway

Unauthorized area

Other:

Required

Check all of the types of incidents that the target has experienced: *

Physical Contact (kicking, punching, spitting, tripping, pushing, taking belongings, slapping, grabbing, hitting, pinching, invasion of personal space)

Verbal Threats (name-calling, put-downs, teasing, insulting remarks, taunting, making threats, spreading rumors/lies, hurtful graffiti)

Psychological Threats (non-verbal actions, social exclusion, intimidation, sending hate notes, social rejection)

Cyber-bullying (misusing technology/social media to harass, tease, threaten, intimidate, post pictures, spread rumors/lies)

Other:

Required

The behaviors are suspected of being based upon the following characteristics (actual or perceived) of the target (check all that apply). *

Gender

Race

National Origin

Disability

Sexual Orientation

Color

Religion

Religious Practice

Sex

Ethnic Group

Weight/Size

Other:

Required

Describe the specific nature of the incident. What happened? (Be as specific as possible). If not included above, identify the date, time and place of the behavior(s)/incident(s). If there are copies of text messages, emails, posts, etc, please submit any copies to a building administrator. *

If there were any adults present, do you think that they were aware of the incident? If so, who were they and what did they do? *

Was the target absent from school or did he/she avoid the setting as a result of the incident? If yes, briefly explain. *

Does the situation continue to occur? *

Yes

Other:

To your knowledge, has anyone said anything to the suspect(s) to stop or deter the behavior? Briefly explain. *

Has anyone reported the incident(s) to another individual? If so, who is this individual? *

By completing this form and writing my full name on the line below, I hereby attest that all information on this document is accurate to the best of my knowledge. *

A copy of your responses will be emailed to the address you provided.

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