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Vestal
Central School District
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Dignity for All Students
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)
Student (Target)
Student (Witness)
Parent/Guardian
Staff Member
Other
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?
Please Select...
I was directly involved in the incident
I observed the incident
I heard about the incident
If this incident is/was specific to a particular school, please indicate which school below:
Please Select...
African Road Elementary
Clayton Avenue Elementary
Glenwood Elementary
Tioga Hills Elementary
Vestal Hills Elementary
Vestal Middle School
Vestal High School
Where did the incident(s) happen? (Check all that apply)
On School Property
Classroom
Hallway
Bathroom
Playground/Recess
Cafeteria
Gym
Locker Room
At a School Function
Off School Property
School Bus
Via Electronic Communication
If Other, please describe below:
What was the type of incident? (Check all that apply)
Physical Contact (kicking, punching, spitting, tripping, pushing, taking belongings)
Verbal Threats (gossip, name-calling, put-downs, teasing, being mean, taunting, making threats)
Social Threats (non-verbal actions, spreading rumors, social exclusion, intimidation)
Abuse (actions or statement that put an individual in fear of bodily harm)
Cyber-bullying (misusing technology/social media to harass, tease, threaten, post photos; i.e. sexti
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?
Please Select...
Yes
No
If "Yes," please include the number of days the students was absent.
Does the situation continue to occur?
Please Select...
Yes
No
Have you reported this incident before?
Please Select...
Yes
No
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 type the answer to the question.