Skip To Main Content

DASA Reporting Form

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.

A printable version of this form can be downloaded below.

DASA Reporting Form (PDF)

Required

Namerequired
First Name
Last Name
Select the statement(s) that best describe the incident. Choose all that apply.required
Have you been absent from school/work as a result of this incident?required
Certificationrequired