DASA Reporting Form

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DASA Reporting Form

The Dignity for All Students Act (DASA) is a New York State law designed to ensure that all public school students experience a safe, supportive, and welcoming environment free from harassment, discrimination, and bullying. Enacted in 2012, DASA aims to protect students from harmful behaviors that may target their race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender, or sex. https://www.nysenate.gov/legislation/laws/EDN/A2

Email *

Name of person completing this form: *

Role of person reporting incident: *

Student Target

Student (Witness)

Parent/Guardian

Staff Member

Other:

Required

Name of alleged victim(s): *

Date of incident: *

YYYY

School building where incident took place (Check all that apply: *

Elementary School

Middle School

High School

Required

Name of offender(s): *

Presumed witness(es): *

What was your involvement in the incident? *

I was directly involved in the incident

I observed the incident

I heard about the incident

Required

Where did this incident happen (check all that apply *

On school property

Classroom

Cafeteria

Gymnasium

On school bus

Hallway

Locker room

At a school function

Off school property

Via electronic communication (text, phone call, email)

Via social media

Other

Required

If "other" is checked, please describe:

Type of incident (check all that apply) *

Physical contact (Hitting, pushing, or other forms of physical aggression)

Verbal threats (Name-calling, insults, threats, or derogatory comments.)

Emotional (Exclusion, humiliation, or actions that harm a student’s self-esteem.)

Cyberbullying (Using technology to intimidate, harass, or demean others)

Other action that disrupts a student’s ability to participate fully in their education by creating a climate of fear, hostility, or distress

Required

If "other" is checked please describe:

Are there other parties involved? (check all that apply) *

Employee

Student

Parent/Guardian

Other

No other parties are involved

Required

From your perspective, what happened? Please describe the nature of this incident. What did the alleged offender say or do? *

If an adult was present or involved, what did they do? *

Is this event based on any of the following known biases? *

Race

Color

Weight/Size

National Origin

Ethnic Group

Religion

Religious Practice

Disability

Sexual Orientation

Gender

Sex

Socioeconomic Status

Other

Required

If "other" is checked please describe:

To the best of your knowledge, were the alleged victim(s) absent from school as a result of the incident? If so how many days were they out for? *

Please describe how this incident affected the student (target). *

Has this situation occurred before? (Mark only one checkbox) *

Yes

Required

Has this situation continued to occur after action(s) have been taken by school staff? *

Yes

I don't know

What do you believe should be done about the situation? *

A copy of your responses will be emailed to the address you provided.

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