DASA Complaint Form

Dignity Act Complaint Form

Building/District Contact List
Main Phone# 607-243-5533
Elementary Contact: Elementary Principal, *7516
Junior/Senior High Contact: Junior/Senior High Principal, *7506
District Contact: Dignity Act Coordinator, *7331

Name of target student: 



School attending: 
Date of incident: (mm/dd/yyyy)
Time of incident: 
This report is being made due to a(n): (may select multiple choices)

Employee, who directly observed an incident or series of incidents.
    Enter Employee's name and title below:

Employee, who was made aware of an incident or series of incidents.
    Enter Employee's name and title below:

Parent or community member.
    Enter Complaint's name and relationship to targeted student below: 

    type name, relationship to targeted student and contact information below:

Other information for above question as needed:
Basis of complaint / grievance: (may select multiple choices)

Race          Religion            Gender

Ethnic Group       Religious Practice       National Origin

Sex           Disability           Sexual Orientation

Color             Weight     

Other/not sure (please briefly explain below):

Explain other from above:
Name of offending person (s), grade and gender: 
Incident is a result of: (may select multiple choices)


Employee conduct

Description of alleged harassment/bullying/discrimination incident(s):
The incident(s) involved: (may select multiple choices)

Physical (direct)- hitting; punching; tripping; kicking; pushing; scratching; ganging up; extortion; damaging property

Social/Relational (direct or indirect)- excluding or threatening to exclude; spreading rumors/gossiping; ostracizing; alienating; using threatening looks/glances

Verbal (direct)- name calling; teasing; intimidating; threatening; taunting; making offensive or discriminatory remarks (rude and or lewd)

Cyberbullying- sending insulting messages or threats by email, text messaging on social media, chat rooms, etc.


Witnesses, if any, or others with knowledge or information important to this investigationm, including contact information for each:

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