4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 ew York State146s Dignity for All Students Act The Dignity Act seeks to provide the State146 ID: 830940
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44444444444444444444444444444444444444444444444444DASA COMPLAINTFORM(Dignity For All Students Act)ew York State’s Dignity for All Students Act (The Dignity Act) seeks to provide the State’spublichis section to be completed by Complainant(person submitting this report)Name ofComplainantRelationship to student: ____Teacher ____ Administrator ____Parent ____Classmate ____Community member Address Home Phone # Cell Phone # Date & Time ofComplaintNamelleged Targeted StudentParent/Guardian Name_____________________ Home Phone#_____________ #Cell Phone # ame of Alleged Offender#1_____________________________________Parent/Guardian Name_____________________ Home Phone#_____________ #Cell Phone # Name of Alleged Offender #2_____________________________________Parent/Guardian Name_____________________ Home PhoneName of Alleged Offender #3_____________________________________Parent/Guardian Name_____________________ Home Phone#_____________ #Cell Phone #______ Location of Incident S
choolGradeBuilding___Classroom___Gym/Lo
choolGradeBuilding___Classroom___Gym/LockerRoom___Hallway___SchoolBus___Cafeteria___FieldTripTechnology(describe)Other(describe)__________________________________ ___________________________________ Behaviors: (Check all that apply) Actual or perceivedraceReligion/ReligiousPractice___Color___Disability___Weight___SexualOrientationNationalOriginGenderEthnicGroupGenderIdentity/ExpressionOther(describe)______________________________________________________________________ 1 of 2(Witness Information) WitnessNameHome Phone # Cell Phone # WitnessName Home Phone # Cell Phone # WitnessName Home Phone # Cell Phone # as Physical InjuryIncurred? ___Yes___No IF YES, Medical AttentionRequired? ___Yes ___No Observable Changes in Targeted Student’s Behavior: (Check all that apply) Attendance___Self- DestructiveBehavior___Grades___AntisocialBehaviorDepression Withdrawal Other(PleaseDescribe _______________________________________________ DESCRIPTIONCIDENTSIGNATURE OFCOMPLAINANTDATEomplaint4444444444444