DASA - Incident Reporting Form

Bronx ASCS is committed to providing a safe, supportive environment free from harassment, bullying or discrimination. The District encourages the involvement of staff, students, parents and community members in the implementation and enforcement of the Dignity for All Students Act (DASA

If you believe you, or someone else, has been the target of harassment, bullying-including cyberbullying-or discrimination, please use this form to report all allegations. Complete this form and return it to the school administrator or Dignity Act Coordinator. Administration will review and respond to each incident in the context of the student Code of Conduct.
Name of person filing the report*
Phone number*
Email*
example@example.com
Identification of Person Reporting Incident*

I am the target of bullying, harassment, or discriminationI observed the incident (witness)I heard or was told about the incident
Relationship to the student on whose behalf you are reporting*

Friend/PeerFamilyTeacher StaffOther
Names of alleged offenders
Name and grade of students being targeted
Name of witnesses if any
Where did the incident happen? (Check all that apply)

ClassroomHallwayGymBathroomCafeteriaLocker RoomAt a School FunctionOn the School BusOff School Property
Types of bias involved (actual or perceived)?: (Check all that apply)

RaceColorWeight/SizeNational OriginEthnic GroupReligionReligious PracticeDisabilitySexual OrientationGender IdentitySexOther
The incident involved the following type of harassment: (check all that apply)

Physical (kicking, punching, spitting, tripping, pushing, taking/damaging belongings)Verbal (name‐calling, put‐downs, teasing, taunting, making threats, offensive comments)Social/relational (non‐verbal actions, spreading rumors, social exclusion, intimidation, gossiping, alienating)Cyberbullying (misusing technology/social media to harass, tease, threaten, post pictures/sexting)Other
Has this situation been reported to anyone else?*

NoYes
I reported this to:
Date Reported:

MonthDayYear
Date
Describe the specific nature of the incident Provide dates and times as specific as possible What did the alleged offender say or do Include any copies of text messages emails etc if possible Attach additional pages if necessary*
What if any observable changes have occurred with the student resulting from the incident ie medical treatment lack of attendance grades social engagement social withdrawal depression selfdestructive behaviors etc*
I do hereby attest that this information is true, accurate, and complete to the best of my knowledge.
Signature*

Clear
Date*

MonthDayYear
Date
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.

**All complaints will be treated in a confidential manner. Anonymous reports may limit the school's ability to respond to the complaint.

*False reporting of incidents may result in disciplinary consequences and may be reported to an appropriate law enforcement agency.

*Any reports made during summer months will be addressed as an administrator is available.
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