Community DASA Complaint Form

Report Bullying, Harassment or Discrimination

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 (required):
* Name(s) of student(s) targeted (required)
* Name(s) of alleged offenders. Please indicate whether employee or student. (required)
* 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. (required)
* The basis of the actual or perceived bullying, harassment or discrimination is: (required)











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




* Contact information: YOUR NAME (required)
YOUR EMAIL
* YOUR PHONE NUMBER (required)

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

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