Franklin CSD Suspected Bullying/Harassment (DASA) Reporting Form

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The Franklin School District is committed to providing a learning environment that promotes respect, dignity and equality. The Board of Education recognizes that harassment, discrimination, hazing, and bullying hinder student learning and achievement. This form is intended to inform school personnel of alleged incidents of harassment. If you are reporting an incident please fill-in the required information below, and click submit. The form will forwarded to the Dignity for All Students Act Coordinator. Thank you for supporting Franklin Central School in providing a safe and supportive learning environment.

Email *

Name of the person completing this form: *

Phone Number: *

Role of person reporting incident *

Student Target

Student (Witness)

Parent/Guardian

Staff Member

Other:

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

Name(s) of alleged offender(s) or person/people exhibiting bullying behavior: *

Who was involved in the incident? *

Student

Employee

Both student and employee

Other:

Name of witness(es) if any: *

Who else saw the suspected bullying incident occur?

Date of Incident *

YYYY

Time of Incident

Time

What was your involvement in the incident? *

I was directly involved in the incident

I observed the incident

I heard about the incident

Where did the incident occur? *

On school property

Classroom

Hallyway

Bathroom

Cafeteria

Gym

Locker Room

At a school function

On a school bus

Off school property

Electronic Communication

Other:

Required

Please identify the type of bullying (as per DASA definition) you are reporting. *

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

Physical contact (punching, kicking, choking, potential for physical injury, spitting, tripping, pushing, taking belongings)

Cyber Bullying (misusing technology(emails, text messages, social media) online impersonation, hacking/stealing information, threats, teasing, harassing, posting pictures (Sexting)))

Psychological (non-verbal actions, spreading rumors, social exclution, intimidation)

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

Other:

Required

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

Types of Bias (check all that apply)

Race

Color

Weight/Size

National Origin

Ethnic Group

Religion

Religious Practice

Disability

Sexual Orientaton

Gender

Sex

Other:

Was this incident reported to an adult when it happened? If so who *

Has this behavior been repeated over time? *

Yes

Does this behavior continue to happen? *

Yes

If so, has the alleged victim asked the alleged aggressor to stop the behavior? *

Yes

Please describe the incident you are reporting. (This field is for fact based details pertaining to the incident only. It is not a forum for assumptions, suggestions, or comments on this, or past incidents.) See below to upload any relevant copies of texts, emails, or etc. *

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

Submit

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