DASA/safety incident reporting form

Carle Place 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.

Today's date *

YYYY

Name of person reporting incident

Optional

Your answer

Person reporting incident (check one): *

Student

Student (witness)

Parent/Guardian

Employee

Other:

Phone

Optional

Your answer

Optional

Your answer

Name of victim (student being bullied, harassed of discriminated against): *

Your answer

Which school does the victim attend? *

Cherry Lane

Rushmore Avenue

Middle School

High School

Relationship to victim: *

Family

Friend

Peer

Stranger

Staff

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

Optional

Your answer

Date(s) and time(s) of the incident(s) *

Your answer

What was your involvement in the incident? *

I was directly involved in the incident

I observed the incident

I heard about the incident

If you were told about the incident, please indicate by whom:

Your answer

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

Classroom

Hallway

Bathroom

Cafeteria

Playground

Gym

Other location on school property

On a school bus

Off school property

Electronic communication

Other:

Required

The incident involved (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 (non-verbal actions, spreading rumors, social exclusion, intimidation)

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

Cyberbullying (misusing technology/social media to harass, tease, threaten, post pictures)

Other:

Required

If you checked "Other" above, please describe what the incident involved.

Your answer

The incident involved: *

Student

School employee

Both student and school 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, email, etc, if possible. *

Your answer

Type 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

Required

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

Yes

If the student was absent, please enter the number of days absent.

Your answer

Does the situation continue to occur? *

Yes

Not sure

Would you like us to follow up with you? *

Yes

If you answered yes to the above, please indicate your preferred method of contact and times you can be reached.

Your answer

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