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DASA Reporting Form

A printable version of this form can be downloaded below.

DASA Reporting Form (PDF)


This is a form to report alleged bullying or harassment, including cyberbullying. If you are a student target, the parent/guardian of a student target, or a school staff member and wish to report an incident of alleged bullying or harassment, please complete this form. Contact the DASA Coordinator for additional information or assistance at any time. Please note that all reported incidents may not fall under the Dignity for All Students Act but will be addressed as per the North Rose-Wolcott discipline policies and procedures at the discretion of the building principal.
Name of Reporterrequired
First Name
Last Name
Relationship to the studentSelect at least one.
Select at least one.
Location of IncidentChoose all that apply.
Choose all that apply.
Select the statement(s) that best describe what happened.Choose all that apply.
Choose all that apply.
Was the student target absent from school as a result of the incident?
Submission of this form indicates that the above information accurately reflects what was stated during the investigation.