Warren Street Academy DASA Reporting Form
Harassment, hazing, or bullying are serious and will not be tolerated. Please use this form to report alleged harassment, hazing or bullying that occurred on school property, at a school sponsored activity or event, on or off school property, on a school bus, or on the way to and/or from school. Any person (student, parent/caregiver, community member, faculty/staff member, etc.) observing, or being the target of bullying, hazing, harassment or perceived bullying, hazing, harassment activity reports the observation. Please complete and return this form to the principal, associate principal, or DASA Coordinator at the students’ school. Contact the school for additional information or assistance.
When did this incident occur:
Your relationship to the target:
Did you witness the incident?
What is the name of target?
What is the age or grade of the target?
Who is being reported as the offender (if Known)?
Where there any possible witness(es), if so who are they:
Where did the incident happen? Choose all that apply:
On the way to/from school
Describe what happened using the selection below. Choose all that apply:
Hitting, kicking, shoving, spitting, hair pulling, or throwing something
Getting another person to hit or harm the student
Teasing, name-calling, making critical remarks, or threatening, in person or by other means
Demeaning remarks or student being made the target of joke(s)
Making rude or threatening gestures
Excluding or rejecting the student, or asking another person to turn against a student
Intimidating (bullying), extorting, or exploiting
Spreading harmful rumors or gossip
Did any of the following Bias(es) apply to the incident?
Auctual or perceived race
What did the alleged offender(s) say or do to the victim?
Is this the first time this has happened?
Did a physical injury result from this incident?
Yes (no medical attention needed)
Yes (medical attention needed)
Evaluation by school nurse
Other medical intervention (please specify in Other)
Is there any additional informational you would like to provide?
Best way to Contact you if we need more information (provide your phone number or email below):
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