DASA Electronic Report Form
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Dignity for All Students Act (DASA) Reporting Form
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.
Definition: conduct, verbal threats, intimidation or abuse that reasonably causes or would reasonably be expected to cause a student to fear for his or her physical safety based on one of the protected classes below, the effect of which reasonable and substantially interferes with a student’s educational performance, opportunities or benefits.
Please select the DASA protected category applicable to the incident that you are reporting. Please also include if this incident is real or perceived:
Select at least 1.
Race
Color
Gender
Weight
Religious Practice
Sex
National Origin
Disability
Religion
Sexual Orientation
Other (define)
Where did the incident occur?
(please identify the specific location)
Enter at least 1 response.
On school property
At a school function
Online (specific social media)
*If online, please provide a printed copy of the incident to the school's principal.
When did the incident occur?
mm/dd/yyyy
Time of the incident
If you were told of the incident, indicate by whom:
Please describe what happened in as much detail as possible:
Name of offender (current student or staff member)
Name(s) of witnesses
Please include first and last names
First Name
Last Name
Witness 1
Witness 2
Witness 3
Witness 4
Has this harassment happened before?
Has this harassment happened before?
Yes
No
If yes, have you reported this previously?
If yes, have you reported this previously?
Yes
No
If you have previously reported this harassment, please indicate to whom it was reported:
Your Name
Your Status
Your Status
Parent
Student
Other (please specify)
Preferred contact information
Please provide contact details
Contact Details
Phone (555)555-1212
Email