Middle-High School 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 MHS

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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Middle-High School DASA Complaint Form

DASA MHS