Community DASA Complaint Form

Report Bullying, Harassment or Discrimination
The purpose of this form is to inform Monroe 2-Orleans BOCES of an incident (or series of incidents) of bullying, harassment, and/or discrimination so we can investigate and conduct appropriate follow through.
 
* By submitting this completed document, you are certifying that all statements on it are accurate and true to the best of your knowledge.   

Today's Date:
Name(s) of student(s) targeted
Name(s) of alleged offenders (please indicated whether employee or student)
Description of the alleged bullying, harassment and/or discrimination witnessed. Please be as specific as possible and include the exact location and date of each incident described.
The basis of the actual or perceived bullying, harassment or discrimination is:











Attach any supporting documentation (i.e. Copies of emails, notes, photos, etc.)
Were there any witnesses?
If YES, please list the names (and contact information if available) for those individuals.
Has the incident/situation been previously reported?
If YES, when and to whom?
Who is the person filling out this form?




Contact information: YOUR NAME
YOUR EMAIL
YOUR PHONE NUMBER

To validate your submission, please answer the following math problem:

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