DASA Incident Reporting Form

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The Indian River School District is committed to providing a safe, supportive environment free from harassment, bullying, and discrimination for all students. The District encourages the involvement of staff, students, parents, and community members in the implementation and reinforcement of the Dignity for All Students Act ("DASA").

If you believe you, or someone else, has been the target of harassment, bullying, cyber-bullying, and/or discrimination, please use this form to report all allegations.

School/district personnel witnessing an incident or receiving a report of an incident must complete and submit this written report within two(2) school days. Note: School/district personnel must also orally notify the principal, superintendent or their designee no later than one school day after witnessing or receiving a report of an incident.

All complaints will be treated in a confidential manner. Anonymous reports may limit the district's ability to respond to the complaint. A prompt and thorough investigation will be conducted for all incident reports.

Please complete and submit this form to a school administrator or Dignity Act Coordinator

The Calcium Primary School Dignity Act Coordinators are Mrs. Freeman, principal, and Mr. Brabant, assistant principal.

Today's Date: *

YYYY

Name of person reporting incident:

Role of person reporting incident *

Student target

student (witness)

Parent/guardian

Staff member

Other:

Phone:

Email:

Name of target (student being bullied, harassed, or discriminated against) *

Name(s) of alleged offender(s): *

Date of incident

YYYY

Time of incident

Time

What was your involvement in the incident? *

I was directly involved.

I observed the incident.

I heard about the incident.

Where did the incident happen? (check all that apply) *

On school property

Classroom

Hallway

Bathroom

Cafeteria

Gym

Locker Room

At a school function

On a school bus

Off school property

Electronic communication

Other:

Required

Type of incident (check all that apply) *

Physical contact (kicking, punching, spitting, tripping, pushing, taking belongings)

Verbal threats (gossip, name-calling, put-downs, teasing, being mean, taunting, making threats)

Psychological (gestures, body language, spreading rumors, social exclusion, intimidation)

Abuse (actions or statements that put an individual in fear of bodily harm)

Cyber-bullying (misusing technology/social media to harass, tease, threaten, post pictures (sexting))

Other:

Required

Who was involved in the incident? *

Student

Employee

Both student and employee

Describe the specific nature of the incident. What happened? (Be as specific as possible). What did the alleged offender say or do? Include any copies of text messages, emails, etc. if possible. *

If there were any adults in the area when this happened, what did they do? *

Types of bias involved (if known): (Check all that apply) *

Race

Color

Weight/size

National origin

Ethnic Group

Religion

Religious practice

Disability

Sexual orientation

Gender

Sex

Other:

Required

Names of others who may have witnessed the incident: *

Was the student absent from school as a result of the incident?

Yes

Unknown

If so, how many days was the student absent?

Does the situation continue to occur?

Yes

Unknown

Clear selection

What do you think should be done about the situation?

You can contact the school administrator/Dignity Act Coordinator, counselor, or other staff member (whoever you are most comfortable with) for information or assistance at any time.

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