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 *
Your answer
Grade of Victim *
Your answer
Date of Incident *
MM
/
DD
/
YYYY
Approximate Time of Incident *
Time
:
Location of Incident *
Your answer
Did you witness the incident? *
If you were not a witness, how was it reported it to you?
Your answer
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... *
Your answer
Name(s) of the individual(s) accused of discrimination, harassment or bullying: *
Your answer
Other possible victims:
Your answer
Were there any witnesses/bystanders to the incident? *
If yes, please identify those witnesses and/or bystanders:
Your answer
Which of the following best indicates the basis of the alleged bullying, harassment and/or discrimination? (Check all that apply): *
Required
Which of the following best describes where the incident occurred? (Check all that apply): *
Required
Which of the following best indicate(s) the type of incident that occurred? *
Required
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") *
Your answer
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