DASA Incident Report - Elementary

Required

NYACK PUBLIC SCHOOLS

LIBERTY ° UPPER NYACK ° VALLEY COTTAGE ELEMENTARY SCHOOLS

DIGNITY FOR ALL STUDENTS ACT

INCIDENT REPORT FORM

Your Name:required

First Name

Last Name

Tel. #:required

Your Role in the Incident: (e.g., witness, alleged victim, student*, parent, teacher, etc.)required

*Students: If you need help completing this report, please ask an adult to help you.

Date(s) of Incident(s):required

Time of Incident(s):required

Names of People Involved, Grade, and Alleged Role in Incident-victim or offenderrequired

Location of Incident(s): (Check all that apply) required

School property

On a school bus

School function/event

Off school property

School property-(specify)

On a school bus-(specify bus # and am/pm route)

School function/event-(specify)

Off school property-(specify/describe)

Description of the Incident(s): Please describe the alleged incident and include as many details as possible such as any relevant gestures and/or written, verbal or physical act(s) and/or any electronic communication. Attach additional sheets if necessary.required

Signature of person completing reportrequired

Attach up to 1 file with a maximum size of 10MB

No file chosen

Date

Must contain a date in MM/DD/YYYY format

**Any person reporting an incident of harassment, discrimination, and/or bullying in good faith is protected from liability claims.

PLEASE SUBMIT THIS COMPLETED FORM TO THE PRINCIPAL OR DIGNITY

ACT COORDINATOR

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DASA Incident Report - Elementary

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