DASA Complaint Form

Name of target student:
Gender:	Male Female
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: Other, 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)	Student and/or Employee conduct
Description of alleged harassment/bullying/discrimination incident(s):
The incident(s) involved: (select one)	Intimidation or abuse, but no verbal threat(s) or physical contact Verbal threat(s) but no physical contact Physical contact but no verbal threat(s) Verbal threat(s) and physical contact
Witnesses, if any, or others with knowledge or information important to this investigationm, including contact information for each: