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DASA Complaint Form
A DASA complaint form must be posted on the school's website and communicated to parents and students on an annual basis. To be completed by the person reporting the incident (or the person receiving the complaint and/or investigating the incident) and submitted to the Dignity Act Coordinator (DAC).
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* Indicates required question
Today's Date
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MM
/
DD
/
YYYY
Name and position of the person reporting the incident (if reporting anonymously, please write "Anonymous") **NOTE: staff members are required reporters
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Your answer
Name of student being bullied, harassed, or discriminated against
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Your answer
Name(s) of alleged offender(s)
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Your answer
Date and time of incident
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Your answer
What was your involvement in the incident?
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I was directly involved in the incident
I observed the incident
I heard about the incident
Required
Where did the incident happen?
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Your answer
Type of incident (check all that apply)
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Physical contact (kicking, punching, spitting, tripping, pushing, taking belongings)
Verbal threats (gossip, name-calling, put-downs, teasing, 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
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
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)
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Race/Color
Weight/Size
National origin/Ethnic group
Religion/Religious practice
Disability
Sexual Orientation
Gender/Sex
Other:
Required
Name(s) of others who may have witnessed the incident
Your answer
Describe the impact this incident had on the student target. Was the student absent from school as a result of the incident?
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Your answer
Does the situation continue to occur?
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Yes
No
What do you think should be done about the situation?
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Your answer
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