Directions: The Bainbridge-Guilford Central School District is committed to providing a safe environment to all members of our community. Despite our best intentions, incidents between students, students and staff do occur at times. If you wish to report a disturbing incident between two or more students, or between a student and staff member, complete this form and return it to the Principal at the Student’s school. Contact the school for additional information or assistance at any time. This form can be completed anonymously by omitting signature and name. Every reported act of bullying will be investigated. Parents of aggressors and targets will be contacted in cases of confirmed bullying.

Dignity for All Students Act (DASA) Incident Reporting Form

To be completed by person reporting the incident (or the person receiving the complaint and/or investigating the incident)

Today’s date: ___________________________ Name of School: ________________________________

Name of person reporting incident: ________________________________________________________

Role of person reporting incident (Check one)

□Student target	□Student (witness)	□Parent/Guardian	□Staff member	□Other

Phone:____________________________	Email: _____________________________________________

Name of target: (student being bullied, harassed, or discriminated against)

_______________________________________________________________________________

Name(s) of alleged Offender(s): ___________________________________________________________

Date(s) and time(s) of incident(s): _________________________________________________________

What was your involvement in the incident?

□I was directly involved in the incident	□I observed the incident	□I heard about the incident

Where did the incident happen? (Check all that apply)

□On school property

□Classroom

□Hallway

□Bathroom

□Cafeteria

□Gym

□Locker room

□At a school function

□On a school bus

□Off school property

□Electronic communication

□Other (describe):

________________________ 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 (describe):

Revised 7/2018

Who was involved in the incident?

□Student	□Employee	□Both 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.

_______________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________ (add extra pages if needed)

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)

□Race

□Color

□Weight/size

□National origin

□Ethnic group

□Religion

□Religious practice

□Disability

□Sexual orientation

□Gender

□Sex

□Other (describe)

Names of others who may have witnessed the incident:

________________________________________________________________________________ Was the student absent from school as a result of the incident?

□ No □ Yes Number of days student was absent: _____________________________________________

Does the situation continue to occur?	□ Yes □ No

What do you think should be done about the situation?

_______________________________________________________________________________________

Please return the completed from to Dignity Act Coordinator or Building Administrator.

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.

Revised 7/2018