DASA/safety incident reporting form
Jericho UFSD is committed to providing a safe, supportive environment free from harassment, bullying or discrimination. 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 – including cyberbullying – or discrimination, please use this form to report all allegations. You may also use this form to report safety incidents you want to make District personnel aware of.

You can complete this form online and it will automatically be directed to the school administrator.  Or you can complete this form and return it to the school administrator or Dignity Act Coordinator. Administration will review and respond to each incident in the context of the student Code of Conduct.

*All complaints will be treated in a confidential matter. Anonymous reports may limit the district’s ability to respond to the complaint.

**False reporting of incidents may result in disciplinary consequences and may be reported to an appropriate law enforcement agency.
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Today's date *
Name of person reporting incident
Person reporting incident (check one): *
Name of victim (student being bullied, harassed, or discriminated against): *
Which school does the victim attend? *
Relationship to victim: *
Name(s) of alleged offender(s): *
Date(s) and time(s) of the incident(s) *
What was your involvement in the incident? *
If you were told about the incident, please indicate by whom:
Where did the incident happen? (check all that apply) *
The incident involved (check all that apply): *
If you checked "Other" above, please describe what the incident involved.
The incident involved: *
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, email, etc, if possible. *
Type of bias involved, if known (check all that apply): *
Was this student absent from school as a result of the incident? *
If the student was absent, please enter the number of days absent.
Does the situation continue to occur? *
Would you like us to follow up with you? *
If you answered yes to the above, please indicate your preferred method of contact and times you can be reached.
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