DASA Electronic Report Form

Page 1 of 1

  Dignity for All Students Act (DASA) Reporting Form
  The purpose of this form is to inform the District of an incident or series of incidents of discrimination or harassment (which includes bullying) so that we can investigate and take appropriate steps.

Definition: conduct, verbal threats, intimidation or abuse that reasonably causes or would reasonably be expected to cause a student to fear for his or her physical safety based on one of the protected classes below, the effect of which reasonable and substantially interferes with a student’s educational performance, opportunities or benefits.
Select at least 1.

(please identify the specific location)
Enter at least 1 response.



  *If online, please provide a printed copy of the incident to the school's principal.
  Select Date
Please include first and last names
Witness 1  
Witness 2  
Witness 3  
Witness 4  



Please provide contact details
Phone (555)555-1212 
 Done  Save  Cancel