DASA Reporting Form
DASA Building Level Coordinators
When you fill out this form, it will be sent to the appropriate building level DASA coordinator. Please fill out all fields to the best of your ability and if you are having trouble with this form, please contact the building principal.
Reporting Information
School
Please Select
Cornwall Central High School
Cornwall Central Middle School
Cornwall Elementary School
Cornwall on Hudson Elementary School
Willow Avenue Elementary School
Today’s Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of person reporting the incident
*
Role of person reporting incident
*
Teacher
Administrator
Staff
Parent/Guardian
Student
Other
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
*
example@example.com
Incident Details
Date of Incident
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Target (student being bullied, harassed or discriminated against)
*
Name(s) of Alleged Aggressor(s)
*
What was your involvement in the incident?
*
Target
Witness
Reporter
Participant
Other
Where did the incident happen?
*
School building
School grounds
School bus
Classroom
Hallway
Cafeteria
Restroom
Locker room
Playground
Athletic field
Off-campus
Other
Other (describe) - location
Electronic Communication
Text message
Email
Phone call
Social media
Instant message
Online post
Video or photo sharing
Other
Type of Incident
*
Bullying
Harassment
Discrimination
Threats
Physical assault
Verbal abuse
Cyberbullying
Hazing
Retaliation
Other
Other (describe) - type of incident
Who was involved in the incident?
*
Student(s)
Staff member(s)
School employee
Parent/guardian
Other student group
Unknown
Other
Other - who was involved
Describe the specific nature of the incident. What happened?
*
Has this been reported to law enforcement?
Yes
No
Unknown
Witnesses, Bias, and Impact
If there were any adults in the area when this happened, what did they do?
Types of bias involved (if known)
Race
Color
Religion
National origin
Sex
Disability
Gender identity
Sexual orientation
Age
Weight/size
Religious practice
Ethnic group
None
Other
Other (describe) - type of bias
Name(s) of others who may have witnessed the incident
Please describe the impact on the target (person being harassed, bullied or discriminated)
Does the situation continue to occur?
Yes
No
Unknown
What do you think should be done about the situation?
If there is any other documentation or evidence that would help with this report, please upload it here or send to your building DASA coordinator
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