Dignity For All Students Act (DASA) - Harassment, Bullying, & Discrimination Reporting Form
Keshequa Central School District is committed to providing a safe & supportive learning environment for all students. If you believe you or someone else has been the target of harassment, bullying (including cyberbullying), or discrimination, please use this form to report all allegations so that the District can investigate and take appropriate action within the context of the Keshequa Code of Conduct.

*All reports will be treated in a confidential manner.
*False reporting of incidents may result in disciplinary consequences.

Today's Date *
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Your Name (first and last name) *
Your answer
Person filling out this form *
Phone Number
Your answer
Email Address
Your answer
Description of alleged harassment, bullying, or discrimination
Date(s) of incident(s) *
Your answer
Where did the incident(s) take place? *
Your answer
Name(s) of alleged offender(s) *
Your answer
Name(s) of victim(s) *
Your answer
Were there any witnesses? *
If yes, list name(s) of witness(es).
Your answer
Describe the incident. (Please be as detailed as possible). *
Your answer
Do you have any supporting evidence related to the incident? (i.e., copies of text messages, social media, photos, notes, emails, etc.). Please list below and save copies.
Your answer
Has the incident been previously reported? *
Required
If yes, when and to whom?
Your answer
The basis of the actual or perceived harassment, bullying, or discrimination is: *
I certify that all statements on this form are accurate and true to the best of my knowledge.
Signature *
Your answer
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