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Fabius-Pompey DASA Incident Reporting Form
This form is to document alleged bullying, harassment, or intimidation that occurred on school property, at a school-sponsored activity or event off school property, on a school bus, or on the way to and/or from school.
If you are a student victim or a school staff member and wish to report an incident of alleged bullying, harassment, or intimidation, complete and submit this online form.
Please be aware that intentionally making a false report or retaliation against any person who reports, is thought to have reported, files a complaint, or otherwise participates in an investigation or inquiry concerning allegations of bullying is prohibited and may result in disciplinary action.
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* Indicates required question
School/Building
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Your answer
Today’s Date
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MM
/
DD
/
YYYY
Role of person reporting incident
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Student that was directly effected
Student Witness
Parent/Guardian
Staff Member
Other
If choice was “other” to the above question please describe below:
Your answer
Name of student that was a direct result of the incident
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Your answer
Name(s) of Alleged Offenders
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Your answer
Dates and Times of incident(s)
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Your answer
What Was Your Involvement of the Incident?
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I was directly involved in the incident
I observed the incident
I heard about the incident
Where did the incident happen?
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On school property
Classroom
Hallway
Bathroom
Cafeteria
Gym
Locker Room
At a school function
On a school bus
Off school property
Electronic communication
Library
Other
If choice was “other” to the above question please describe below:
Your answer
Type of Incident
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Choose
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
If choice was “other” to the above question please describe below:
Your answer
Who was involved in the incident?
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Your answer
Describe the specific nature of the incident. What happened? (Be as specific as possible) What did the alleged offender say or do?
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Your answer
Where there any adult(s) present? If so, please list them and their involvement.
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Your answer
Where there others who may have witnessed the incident? If so, please list them and their involvement.
Your answer
Was this incident one-sided?
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Your answer
Is the behavior unwanted?
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Your answer
Was there a power imbalance being used in this incident(s)?
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Your answer
Was this incident(s) meant to cause emotional or physical harm?
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Your answer
Does the incident(s) continue or is it repeated?
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Your answer
Was the student absent from school as a result of the incident?
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Yes
No
Did the incident involve: race, color, weight/size, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender, sex, and/or other)? If so, please identify and describe below.
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Your answer
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