DASA Incident Reporting Form For Elementary School

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RACS is committed to providing a safe, supportive environment free from violence, 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, someone else, or a school, as been the target of harrassment, bullying, cyberbullying, or discrimination, or you have concerns about a student, please use this form to report all allegations.

You can complete this form online and it will automatically be directed to the school administrator or DASA Coordinator. Administration will review and respond to each incident in the context of the student Code of Conduct (available for review on the district website)

Today's Date

YYYY

Name of person reporting incident

Role of person reporting incident
*

Student Target

Student Witness

Parent/Guardian

Staff

Other

Required

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

Name(s) of alleged offender(s)
*

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 happen (check all that apply)
*

On school property

Classroom

Cafeteria

Bathroom

Hallway

Gym

Locker room

On a school bus

At a school function

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 (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 (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?
*

Names of others who may have witnessed the incident
*

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

Submit

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