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DASA Incident Reporting Form

Marcus Whitman Central School District's DASA Coordinators have been trained in methods to respond to human relations in the areas of race, color, weight, national origin, ethnic group , religion, religious practice, disability, sexual orientation, gender and sex.

All information and complaints will be treated in a confidential manner.

Date Picker (mm/dd/yyyy)

Name of Person Reporting Incident

Person Reporting Incident

Student Student (witness) Parent/Guardian Staff Member Self Other

Other:

Phone

Ext

Email Field

Name of Target

Target Attends Which School Building

High School Middle School Gorham Intermediate Middlesex Valley Primary

Relationship to Target

Friend Family Peer Stranger Staff Self

Name(s) of Alleged Offenders

Date(s) and Time(s) of Incident

What is your involvement in the incident?

I was directly involved in the incident I observed the incident I heard about the incident

Where did the incident happen?

On school property Classroom Hallway Bathroom Cafeteria Gym Locker Room At a school function On a school bus Off school property Other

If other:

In incident involved

Physical Contact(kicking, spitting, tripping, pushing, taking belongings) Verbal Threats (gossip, name-calling, put-downs, teasing, being mean, taunting, etc) Abuse (actions or statements that put an individual in fear of bodily harm) Psychological (non-verbal actions, spreading rumors, social exclusion, intimidation) Cyberbullying (misusing technology/social media to harass, tease, threaten, sexting) Other

If other:

The incident involved

Student Employee Both student and employee

Describe the specific nature of the incident. Be as specific as possible. What happened? If you have any copies of text messages, emails, etc.

Types of bias involved

Race Color Weight/size National origin Ethnic Group Religion Religous practice Disability Sexual Orientation Gender Sex Other

If other

Name of witness, if any

Was the student absent from school as a result of the incident?

Yes No

If absent, enter number of days absent

Please send a confirmation email to the address below:

Please provide an email address where we can send a link to your current form.

Email Address :