DASA Bullying/Harassment Reporting Form

**NOTE: False reporting of an incident is against state law and school policy 7311. Section 240.50 of the New York State Penal Law states: A person is guilty of falsely reporting an incident when, knowing the information reported, conveyed or circulated to be false or baseless, he/she initiates a false report or warning of an alleged occurrence or impending occurrence of a crime, catastrophe or emergency under circumstances in which it is not unlikely that public alarm or inconvenience will result. This is a class A misdemeanor.


Dignity for All Students Act Bullying/Harassment Reporting Form

No student shall be subjected to harassment by employees or students on school property or at a school function; nor shall any student be subjected to discrimination based on a person's actual or perceived race, color, weight, national origin, ethnic group, religion, religious practice, disability, sexual orientation, gender (including gender identity or expression), or sex by school employees or students on school property or at a school function.

Please fill out this reporting form to describe any instances of harassment (including bullying) or discrimination that you have witnessed or experienced on school property or at a school function. This may also include cyberbullying on any social media website which may impact an individual's educational experience or attendance. Please fill out all questions with as much detail and clarity as possible so that we may better respond to your particular situation.

Please provide the name of the person filling out this report.
Please provide a phone number so we may contact you for further information if needed.
Please provide an email address.
Are you the person being harassed (bullied) or discriminated against?   Yes   No
If you are NOT the person being harassed (bullied) or discriminated against, have you witnessed someone else being harassed (bullied) or discriminated against?   Yes   No
If you witnessed or are the victim of an incident of harassment (bullying) or discrimination, please provide the name of the target of harassment (bullying) or discrimination. If you DO NOT know the name of the target, please enter the word "Unknown."
Where is the harassment (bullying) or discrimination occurring?
If you selected "Other School Property" for the above question, please specify.
Please describe with as many details as possible the event of harassment (bullying) or discrimination.


When you have filled in the answers above to the best of your ability, please click "Submit."



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