Olean CSD - DASA Incident Report Form

1.	What is the name of the school this incident occurred in?*
	What is the name of the school this incident occurred in?* Olean High School Olean Intermediate Middle School East View Elementary School Washington West Elementary School

2.	Today's Date:
	mm/dd/yyyy

3.	Name of person reporting incident:

4.	Phone:

5.	Email address:

6.	Role of person reporting incident:*
	Role of person reporting incident:* Student Target  Student (witness)  Parent/Guardian  Staff Member   Other, please specify

7.	Name of target: (student being bullied, harassed, or discriminated against)

8.	Name(s) of Alleged offender(s):

9.	Date(s) and time(s) if incident(s):

10.	What was your involvement in the incident?
	What was your involvement in the incident? I was directly involved in the incident  I observed the incident  I heard about the incident

11.	Where did the incident happen? (check all that apply)
	On school property  Classroom  Hallway  Bathroom  Cafeteria   Gym  Locker Room  At a school function  On a school bus  Off school property   Electronic communication   Other, please specify

12.	Type of incident: (check all that apply)
	Physical contact (kicking, punching, spitting, tripping, pushing, taking belongings)    Verbal threats (gossip, name calling, put-downs, teasing, being mean, taunting, making threats)    Psychological (non-verbal actions, spreading rumors, social exclusion, intimidation)    Abuse (actions or statements that put an individual in fear of bodily harm)    Cyber-bullying (misusing technology/social media to harass, tease, threaten, post pictures(sexting))    Other, please specify

13.	Who was involved in the incident?
	Who was involved in the incident? Student Employee Both student and employee

14.	Describe the specific nature of the incident. What happened? (be as specific as possible.) What did the alleged offender say or do? Include any text messages, emails, etc. if possible.

15.	If there were any adults in the area when this happened, what did they do?

16.	Types of bias involved (if known): (check all that apply)
	Race  Color  Weight/size  National origin  Ethnic group   Religion  Religious practice  Disability  Sexual orientation  Gender   Sex   Other, please specify

17.	Names of others who may have witnessed the incident:

18.	Was the student absent from school as a result of the incident?
	Was the student absent from school as a result of the incident? No If yes, number of days absent

19.	What do you think should be done about the situation?

	You may contact the school administrator, Dignity Act Coordinator, counselor, or other staff member (whoever you are most comfortable with) for information or assistance at any time. DASA Coordinators are: High School: Mr. Andreano, Mrs. Hodara, OIMS: Mr. Trietley, Mrs. DiCerbo, East View: Mr. Crawford, and Washington West: Ms. Stuff.