Vestal CSD

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DASA Incident Reporting Form
The Dignity for All Students Act ensures that all students are educated in a safe, welcoming and affirming environment. Vestal cares, and so do you. Please complete this Dignity for All Students Act reporting form and return it to a school administrator or Dignity Act Coordinator. Including your name is optional; All complaints will be treated in a confidential manner. Anonymous reports may limit the district's ability to respond to the complaint. 

Role of person reporting incident (Check one)




Name of target (Student being bullied, harassed or discriminated against)
Name(s) of alleged offender(s)
Date(s) and time(s) of incident(s)
What was your involvement in the incident?
If this incident is/was specific to a particular school, please indicate which school below:
Where did the incident(s) happen? (Check all that apply)











If Other, please describe below:
What was the type of incident? (Check all that apply)




If the Type of Incident is not available to check, please describe it below:
Describe the specific nature of the incident:
Was the student absent from school as a result of the incident?
If "Yes," please include the number of days the students was absent.
Does the situation continue to occur?
Have you reported this incident before?
If "Yes," who did you report it to?
Is there any other information that you would like to share about this event?
Your Name (Optional)

To validate your submission, please answer the following math problem:

3 + 8 =