DASA Reporting System
Student Bullying Report Form
Please complete, responding only to the questions that you feel comfortable answering and are able to accurately answer. You may choose to include your name at the bottom of the form, or you may choose to submit it anonymously. Please note that the District's ability to investigate an anonymous complaint may be limited, and the District prohibits retaliation against anyone who files a bullying report.
Describe what happened/what is happening:
When did it happen?
Provide Date and Time below:
Where did it happen?
In the school building (be specific in comments box below)
On school grounds outside the building
On the school bus
At a school event (list specific event below)
Other (please specify below)
Who was committing the bullying (if you don't know the bully's name(s)describe him or her)?
Who was the victim of the bullying (if you don't know his/her name, describe him/her)?
Did anyone else witness the bullying (if 'yes' please list)?
List witnesses below
Were you or others physically hurt (please explain in comments box)?
Was there damage to anyone's personal property (please explain)?
Have you or the victim missed any school or made any changes to your daily routine as a result of the incident(s)?
Have you told anyone about the bullying?
Other family member
Other school staff
Other, please specify
Have you previously filed a bullying report (this information is used to determine if retaliation is occurring)?
Your age and grade:
How can we contact you?
Number or Address
The Dignity for All Students Act amends Education Law to put in place procedures for creation of a school environment free of discrimination and harassment. The law came into effect on July 1, 2012. "The legislature finds that students' ability to learn and to meet high academic standards and the school's ability to educate its students, are compromised by incidents of discrimination or harassment..."
The Allegany-Limestone School District condemns and prohibits all forms of discrimination and harassment of students based on race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender, or sex by school employees or students on school property and at school sponsored activities and events that take place off school property.
Just an example.