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Report Bullying

New York State’s Dignity for All Students Act (DASA) seeks to provide the State’s public elementary and secondary school students with a safe and supportive environment free from discrimination, intimidation, taunting, harassment, and bullying on school property, a school bus and/or at a school function. DASA took effect on July 1, 2012. The purpose of this form is to inform the district of an incident of discrimination or harassment (which includes bullying) so that we can properly investigate. DASA defines harrassment as the creation of a hostile environment by conduct or by verbal threats, intimidation or abuse that has or would have the effect of unreasonably and substantially interfering with a student’s educational performance, opportunities or benefits, or mental, emotional or physical well being. It also includes conduct, verbal threats, intimidation or abuse that reasonably cause or would reasonably be expected to cause a student to fear for his or her physical safety.

Please indicate which DASA protected category(ies) the incident falls under (includes real or perceived): *:
Race Color Weight National Origin Ethnic Group Religion Religious Practice Disability Sexual Orientation Gender Sex Other
Please indicate which school the child attends.*:
Corinth Elementary School Corinth Middle School Corinth High School
When did the incident occur?*:
Time (please be specific)*:
How did you find out about this incident? *:
I witnessed the incident directly. I was told about the incident.
Location*:
If you were told, please indicate by whom:*:
Describe what happened in as much detail as possible. *:
Name of the offender (current student or staff member); if possible include both first and last names.*:
Name of victim (current student); if possible give first and last name.*:
Please list any other witnesses. Include first and last names if witnesses if possible. *:
Witness 1

Witness 2

Witness 3

Witness 4

Witness 5



Your name and status *:
Parent

Student

Other

Preferred contact information (please provide contact details next to your selection): *:
Phone (please provide the best number where you can be reached):

E-Mail (please provide your email address):