Dasa Reporting Form Questar III DASA Complaint Form "*" indicates required fields Questar III DASA COMPLAINT FORM To be completed by person reporting the incident (or the person receiving the complaint and/or investigating the incident) and submitted to the Dignity Act Coordinator (DAC).Today's Date* MM slash DD slash YYYY School Building*Columbia High SchoolDonald R. Kline Technical SchoolGeorge Washington SchoolMarilyn A. Noonan School at DurhamPaul Puccio School at Maple HillPre-K Programs (Multiple Locations)Questar classes at Columbia High SchoolRensselaer AcademyRobert H. Gibson Technical SchoolRobert H. Gibson Technical School - Special EducationRobin Sobol Transition AcademySackett Educational CenterSTEM High School and New VisionsTech Valley High SchoolVirtual Learning AcademyRole of the person reporting the incident: (Check one)* Anonymous report Student (target) Student (witness) Parent/Guardian Staff Member Other: (Select to enter text) Role of the person reporting the incident:Contact information for person reporting the incident:*Name:Phone:E-mail:Who was involved in the incident?: (Check all that apply)* Student Employee Other: (Select to enter text) Who was involved in the incident?*Name of Target: (Student being bullied, harassed, or discriminated against):*Name(s) of alleged offender(s):* Add RemoveAdd additional rows for multiple names.Date of the incident:* MM slash DD slash YYYY Time of the incident:* Hours : Minutes AM PM AM/PM Name(s) of others who may have witnessed the incident:* Add RemoveAdd additional rows for multiple names.What was 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? (Check all that apply)* On School Property Cafeteria On a school Bus Hallway Bathroom Classroom Gym Off School Property Locker Room At a school function Electronic Communication: Select to enter text) Other: (Select to enter text) Electronic Communication (Describe):Other (Describe):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) Psychological (non-verbal actions, spreading rumors, social exclusion, intimidation) Abuse (actions or statements that put an individual in fear of bodily harm) Cyberbullying (misusing technology/social media to harass, tease, threaten, post pictures (sexting)) Other: Select to enter text. Other (Describe):Describe the specific nature of the incident. What happened? (Be as specific as possible). What did the alleged offender say or do? Include any copies of text messages, emails, etc. if possible. (Add extra pages if needed)*File Upload Drop files here or Select files Max. file size: 30 MB. ZIP files are not an acceptable file typeWhat happened directly before the incident?*What happened directly after?*To your knowledge is there a history of incidents between those involved?* No Yes, explain: Yes (Describe):Did any school employee respond to the incident?* No Yes. Please identify the school employee and describe the response/actions taken that you are aware of. Please identify the school employee and describe the response/actions taken that you are aware of.Types of bias involved (if known): (Check all that apply)* Race Color Weight/Size National origin Ethnic group Religion Religious Practice Disability Sexual Orientation Gender Sex Other: (describe) Other (Describe):Please describe why you believe the incident(s) was based upon the above factors of actual or perceived race, ethnic group, national origin, color, religion, religious practice, disability, gender, sexual orientation, sex, weight or other (if known):*Before making this written report, did you verbally or otherwise notify the principal, Dignity Act Coordinator, or other Questar III administrator of this incident(s)?* No Yes. When and how did you notify them? Yes. When and how did you notify them?To your knowledge has any other individual notified the principal, the Dignity Act Coordinator, or other Questar III administrator of this incident(s)?* No Yes. Who? Yes. Who?If there is any other information you feel relevant, please provide it here: You can contact the school administrator, Dignity Act Coordinator, counselor, or other staff member (whoever you are most comfortable with) for information or assistance at any time. PhoneThis field is for validation purposes and should be left unchanged.
