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:
Reporter's(Your) Name:
Your answer
Your relationship to the target:
Did you witness the incident?
What is the name of target?
Your answer
What is the age or grade of the target?
Your answer
Who is being reported as the offender (if Known)?
Your answer
Where there any possible witness(es), if so who are they:
Your answer
Where did the incident happen? Choose all that apply:
Describe what happened using the selection below. Choose all that apply:
Did any of the following Bias(es) apply to the incident?
What did the alleged offender(s) say or do to the victim?
Your answer
Is this the first time this has happened?
Did a physical injury result from this incident?
Is there any additional informational you would like to provide?
Your answer
Best way to Contact you if we need more information (provide your phone number or email below):
Your answer
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