DASA Complaint Form
This form is to be used to report an incident of bullying, harassment or discrimination. It will be submitted to the Dignity Act Coordinator (DAC) for review.
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First and Last Name, and Role of Person Reporting the Incident (e.g. John Smith, Teacher) *
Contact Information  (Email Address and Phone Number) *
Name of target (student being bullied, harassed or discriminated against). *
Name of alleged offender(s) *
Date/Time of incident *
What was your involvement in the incident *
Where did the incident happen? (Check all that apply) *
Required
Type of Incident *
Who was involved in the indident? What are their roles? (student, teacher, coach, parent, etc.) *
Describe the specific nature of the incident. What happened? What did the alleged offender say/do? Be as specific as possible. *
If there were any adults in the area, what did they do? *
Did the alleged offender have any bias/discrimination? (check all that apply) *
Required
Names of others who may have witnessed the incident?
Describe the impact this may have had on the student (absent from school, afraid, etc.)
Does the situation continue to occur? *
What do you think should be done about the incident? *
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