DASA Incident Reporting Form
AHS students and persons in parental relation to students may use this form to report incidents of bullying, harassment, and discrimination to the AHS Dignity Act Coordinator.

Please fill in as much information as possible.
Name of person reporting incident
You may leave this question blank if you wish to report confidentially.
Email address of person reporting incident
You may leave this question blank if you wish to report confidentially.
Phone number of person reporting incident
You may leave this question blank if you wish to report confidentially.
What is your role?
Clear selection
Name of student target (student being bullied, harassed, or discriminated against)
Name(s) of alleged offender(s)
Date and time of incident
What was your involvement in the incident?
Clear selection
Where did this incident happen? Check all that apply.
What type of incident was this? Check all that apply.
What happened? Be as specific as possible.
What did the alleged offender say or do? Include any copies of text messages, emails, etc. if applicable.
If there were any adults in the area when this happened, what did they do?
What type of bias was involved (if known)? Check all that apply.
Please provide the name(s) of anyone else who may have witnessed the incident.
Was the student absent from school as a result of this incident? If yes, how many days was the student absent?
Does the situation continue to occur?
What do you think should be done about the situation?
Submit
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This form was created inside of Academy of Health Sciences Charter School.