Elementary DASA Complaint Form

RESOURCES

New York’s Dignity for All Students Act (DASA)
The Cyberbullying Research Center
Bullying Basics from Teaching Tolerance
Bullying Tips for Students from Teaching Tolerance

BULLYING & HARASSMENT ANONYMOUS INCIDENT REPORTING FORM

If you have any information regarding bullying/harassment and would like to report this information anonymously, please fill out the following form to the best of your ability and click submit. Please note: Making false allegations, providing discriminatory statements and making defamatory statements is prohibited and engaging in such activity will be reported to the appropriate authorities.

If you fear that a student is in immediate danger, please call the Lake Placid Village Police Department at 518-523-3306, the New York State Police at 518-897-2000, or 911.

DASA Elementary

21 Questions

1) Name (optional)

2) Contact Information (optional) (optional)

3) Target/Victim's Name (first & last) *

4) Target's Grade *

5) Target's Age *

6) Alleged Bully's Name (first & last) *

7) Alleged Bully's Grade *

8) Alleged Bully's Age *

9) Name of Witness #1 (optional)

10) Wintess #1's Grade (optional)

11) Witness #1's Age (optional)

12) Name of Witness #2 (optional)

13) Witness #2's Grade (optional)

14) Witness #2's Age (optional)

15) Date and Time of Incident *

16) Frequency of Incidents *

17) Which statement(s) best describes what happened? (choose all that apply) *

18) This field is required. Where did the incident happen? (choose all that apply) *

19) Describe what happened. *

20) In witnesses were involved, describe their role in the incident. *

21) List evidence of bullying (letters, text, posts, photos, etc) *

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Elementary DASA Complaint Form

DASA Elementary