DASA Incident Report - Secondary - Nyack Middle School

NYACK PUBLIC SCHOOLS
NYACK MIDDLE SCHOOL ° NYACK HIGH SCHOOL
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

Date(s) of Incident(s):required

Time of Incident(s): required

Names of People Involved, Grade, and Alleged Role in Incident-victim or offender:required

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

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 nature of the alleged incident and include any relevant gestures and/or written, verbal or physical act(s) and/or any electronic communication. Attach additional sheets if necessary. required

Is there a history of incidents involving the same alleged offender(s) and victim(s)? Please describe.required

Other actual or perceived characteristics (Specify)

Injuries:

Has any physical injury or injuries resulted from this/these incident(s)?required

Yes

No

If yes, was medical treatment required?required

Yes

No

If yes, what were the injuries that required medical treatment?required

Identify what harm you believe was or may have been caused by the alleged incident. Check all that apply.required

Physical or emotional harm

Creation of a hostile educational environment

Substantial disruption or interference with orderly operation of school or rights of others

Severe or pervasive interference with student’s schooling or educational performance

Witnesses:

Identify below any witnesses or others who you know or have reason to believe may have relevant information regarding the alleged incident. Indicate if student, parent, staff member or other.required

Signature of person completing reportrequired

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

No file chosen

Daterequired

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

FOR ADMINISTRATIVE USE ONLY:

Date Received:

Must contain a date in MM/DD/YYYY format

Received by:

Date DAC received incident report:

Must contain a date in MM/DD/YYYY format

Date Principal was notified of incident:

Must contain a date in MM/DD/YYYY format

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DASA Incident Report - Secondary

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