Monday, December 11, 2017


DIGNITY FOR ALL STUDENTS (DASA)
INCIDENT RE
PORT FORM

The purposse of this form is to inform the district of an incident or series of incidents of bullying, harassment, and/or discrimination so we can investigate and take appropriate steps.  If you are a student that feels unsafe or the parent of a child that feels that way, fill out this form and speak directly with the Dignity for All Students Coordinator (Mr. Harper) as soon as possible so we can address your concerns.  Additional contact information may be obtained via our district website.



Items denoted with a red asterisk * are required.
Dignity for all Students (DASA) Incident Report Form
 * Full Name
 
First Name
M.
Last Name
 * Location of Incident
 
 * Grade
 
 * Location of Incident
 
Date and Time of Incident
 
 * Describe the Incident
 
List the name(s) of the individuals accused of bullying, harassment and/or discrimination
 
Were there any witnesses
 

If yes, list the name(s) of the individual(s)
 
Your Name
 
Current date and time
 
Your Phone Numner