DASA Incident Reporting Form

Incident Reporting Form

(For District/School Files Only)

To be completed by person reporting the incident (or the person receiving the complaint and/or investigating the incident)
School District:*
School:*
Dignity Act Coordinator:
Position:*
Todays date:*

MonthDayYear
Date
Name of the person reporting the incident:*
Role of person reporting incident: (Check one)*

Student TargetStudent (Witness)Parent/GuardianStaff MemberOther
Phone:*
Email:*
example@example.com
Name of target: (student being bullied, harassed, or discriminated against)*
Name(s) of alleged offender(s):*
Date(s) and time(s) of incident:*
What was your involvement in the incident?:*

I was directly involved in the incidentI observed the incidentI heard about the incident
Where did the incident happen?: (Check all that apply)*

On school propertyClassroomHallwayBathroomCafeteriaGymLocker RoomAt a school functionOn a school busOff school propertyElectronic CommunicationOther
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
Who was involved in the incident?:*

StudentEmployeeBoth student and employee
Describe the specific 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.*
If there were any adults in the area when this happened what did they do?*
Types of bias involved (if known): (Check all that apply)*

RaceColorWeight/SizeNational OriginEthnic GroupReligionReligious PracticeDisabilitySexual OrientationGenderSexOther
Name(s) of who else may have witnessed the incident?*
Was the student absent from school as a result of the incident?*

NoYes - How many days was the student absent?
Does the situation continue to occur?*

YesNo
What do you think should be done about the situation?*
You can contact the school administrator, Dignity Act Coordinator, counselor, or other staff member (whoever you are most comfortable with) for information or assistance at any time.
Should be Empty: