CCS DASA Incident Reporting Form
Please use this form to report an incident of bullying, harassment or discrimination. The form will be anonymous, unless you include your name as the reporter. The completed form will be submitted to the building principal for investigation and, if appropriate, corrective action. If there is an immediate threat, or you fear a student is unsafe, speak with the building principal immediately, then complete the form.
Student Victim's Name *
Grade of Victim *
Date of Incident *
Approximate Time of Incident *
Location of Incident *
Did you witness the incident? *
If you were not a witness, how was it reported it to you?
Describe the incident. Be as specific as possible about what occurred. For example, if profanity was used, please state the actual profane words used; if a threat was made, please state what the aggressor said, etc... *
Name(s) of the individual(s) accused of discrimination, harassment or bullying: *
Other possible victims:
Were there any witnesses/bystanders to the incident? *
If yes, please identify those witnesses and/or bystanders:
Which of the following best indicates the basis of the alleged bullying, harassment and/or discrimination? (Check all that apply): *
Which of the following best describes where the incident occurred? (Check all that apply): *
Which of the following best indicate(s) the type of incident that occurred? *
To your knowledge, who was involved in the incident?
What is your relationship to the student victim? *
I certify that all statements on this form are accurate and true to the best of my knowledge (Enter name below or write "Anonymous") *
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