DASA Electronic Report Form

	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