Dignity for All Students Act (DASA) Bullying Report Form

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Corinth Central School District

DASA is designed to protect public schools students from bullying by employees or other students based on actual or perceived race, color, weight, national origin, ethnic group, religion, religious practice,disability, sexual orientation, gender, or sex.

The purpose of this form is to inform the District of an incident or series of incidents of discrimination or harassment (which includes bullying) so that we can investigate and take appropriate steps.

Definitions
Bullying - An unwanted, aggressive behavior that involves a real or perceived power imbalance. The behavior is repeated, or has the potential to be repeated, over time.

Harassment - The creation of a hostile environment by conduct or verbal threats, intimidation, or abuse that interferes with a student’s educational performance or mental, emotional or physical well-being.

Date the incident occurred.
*

YYYY

Time the incident occurred. (Please be specific.)

Time

Where did this incident occur?
*

At Corinth Elementary School

At Corinth Middle School

At Corinth High School

Other

How did you find out about this?
*

I witnessed the incident directly.

I was told about the incident.

If you were told list by whom

What DASA category (real or perceived) do you believe this incident is related to?
*

Race

Color

Weight

Ethnic Group

National Origin

Religion

Religious Practice

Sexual Orientation

Disability

Gender

Sex

Other

Required

Describe what happened in as much detail as possible.
*

Name of the offender (current student or staff member); if possible include both first and last names.

Name of the victim (current student); if possible include both first and last names.

Please list any other witnesses and include first and last names.

Has this bullying/harassment happened to the victim before?

Yes

Clear selection

If the incident has happened before, have you reported it to anyone?

Yes

Clear selection

If you have reported this behavior before, to whom did you report? Please give first and last names.

Your status

Student

Parent

Staff

Clear selection

Please provide your first and last name. If you would like to submit this form anonymously do not complete this section.

Please provide the best phone number where we can reach you. If you would like to submit this form anonymously do not complete this section.

Please provide your email address. If you would like to submit this form anonymously do not complete this section.

Submit

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This form was created inside of Corinth Central School. Report Abuse

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