DASA Complaint Form

Dignity Act Complaint Form

Building/District Contact List
Main Phone# 607-243-5533
Elementary Contact: Laurie Hopkins- Halbert, Elementary Principal, *7516
Junior/Senior High Contact: Chris Arnold, Junior Senior High Principal, *7506
District Contact: Stephanie Betts, Dignity Act Coordinator, *7501

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)

 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:

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