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DASA Complaint Form
The Dignity for All Students Act (DASA) was established to protect all students from Harassment, Bullying, and Discrimination. DASA became effective on July 1, 2012 and was amended to include Cyberbullying effective July 1, 2013.
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* Indicates required question
Role of Person Reporting the Incident
*
Anonymous Report
Student being Targeted
Student (Witness)
Parent/Guardian
Staff Member
Other
Phone Number
Your answer
Email
Your answer
Name of Targeted Student (Student being Bullied, Harassed, or Discriminated against)
*
Your answer
Name(s) of alleged offender(s)
*
Your answer
Date, Time, and Location of Incident
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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)
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On School Property
Classroom
Cafeteria
Gym
On a school bus
Off school property
Hallway
Locker Room
Bathroom
At a School Function
Through 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? (Part One)
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Student(s)
Employee(s)
Both Student(s) and Employee(s)
Required
Name who was involved in the incident (Part Two)
*
Your answer
Describe the 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!
*
Your answer
If there were any adults in the area during the incident, who were they? and what did they do in response to the incident?
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Your answer
Type of Bias Involved (Check ALL that apply)
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Race
Religion
Sex
Color
Religious Practice
Weight/Size
Disability
National Origin
Sexual Orientation
Ethnic Group
Gender (Including Gender Identity and Expression)
Religon
Required
Name(s) of others who may have witnessed the incident:
*
Your answer
Was the student absent from school as a result of the incident?
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No
Yes
What were the number of days that the student was absent DUE to the incident?
Your answer
Describe the impact the incident has had on the student (target):
*
Your answer
Does the situation continue to occur?
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Yes
No
Other:
Disciplinary Action Taken (FACULTY ONLY):
Your answer
Internal Comments (FACULTY ONLY):
Your answer
Is it a Material Incident? (FACULTY ONLY):
Yes
No
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