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DASA incident Reporting Form
Regulation - GENERAL COMMITMENTS 0015.2
To be completed by person reporting the incident (or the person receiving the complaint and/or investigating the incident)
You can contact the school administrator, Dignity Act Coordinator, counselor or other staff member (whoever you are most comfortable with) for information or assistance at any time.
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OHM BOCES Instructional Program:
Career and Technical Education (CTE)
P-TECH
Clear selection
Today’s date:
*
MM
/
DD
/
YYYY
Name of person reporting incident:
*
Your answer
Role of person reporting incident (Check one)
*
Student Target
Student (witness)
Parent/Guardian
Staff Member
Other:
Phone:
*
Your answer
Email:
*
Your answer
Name of target: (student being bullied, harassed, or discriminated against)
*
Your answer
Name(s) of alleged offender(s):
*
Your answer
Date(s) and time(s) of incident(s):
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Your answer
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 OHM BOCES Property
Classroom
Hallway
Bathroom
Cafeteria
Gym
Locker Room
At an OHM BOCES Function
On an OHM BOCES Bus
Off OHM BOCES Property
Electronic Communication
Other:
Required
Type of incident: (check all that apply)
*
Physical Contact (kicking, punching, spitting, tripping, pushing, taking belongings, etc.)
Verbal Threats (gossip, name-calling, put-downs, teasing, being mean, taunting, making threats, etc.)
Psychological (non-verbal actions, spreading rumors, social exclusion, intimidation, etc.)
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], etc.)
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?
*
Your answer
If there were any adults in the area when this happened, what did they do?
*
Your answer
Types of bias involved, if known: (check all that apply)
Color
Disability
Ethnic Group
Gender
National Origin
Race
Religion
Religious Practice
Sex
Sexual Orientation
Weight/Size
Other:
Names of others who may have witnessed the incident:
Your answer
Was the student absent from school as a result of the incident?
*
Yes
No
Number of days student was absent:
Your answer
Does the situation continue to occur?
*
Yes
No
What do you think should be done about the situation?
*
Your answer
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