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Dignity for All Students Act (DASA) Complaint Form

The Dignity for All Students Act (DASA) ensures that all students in New York State public schools have the right to learn in a safe, supportive, and respectful environment free from harassment, bullying, and discrimination. If you believe that a student has been the target of such behavior, please complete the form below to submit a complaint.

To fill out the online form in your preferred language, please use the menu in the top left corner to select your language.

Para completar el formulario en línea en su idioma preferido, utilice el menú en la esquina superior izquierda para seleccionar su idioma.

Downloadable PDF

If you prefer to submit your complaint using a paper form, downloadable PDF versions are available in both English and Spanish below.

Si prefiere presentar su queja mediante un formulario en papel, encontrará versiones en PDF descargables disponibles en inglés y español a continuación.

English form Download

Spanish form Download

Targeted Student Information

(Complete a form for each targeted student)

Name *

Student ID Number (Number) *

Grade *

School *

Complaint Information

Date of Incident *

Date Incident Reported to School *

Location of Incident *

Complaint Source *

Alleged Offender(s) Information

Name(s) of Alleged Offenders	Position (Student, Teacher, TA, etc.)	Student Number (if offender is a student)

Witness Information

Name(s) of Witness(es)	Position (Student, Teacher, TA, etc.)	Student Number (if witness is a student)

Summary of Complaint/Incident

(include names, dates, times and other specific information) *

If the space above is insufficient, please attach additional document.

List of Allowed file types

Incident Type (check all that apply) *

1(a) Occurred on school property
1(b) Occurred at a school function off school property
2(a) Intimidation or abuse but no verbal threat or physical contact
2(b) Verbal threats but no physical contact
2(c) Physical contact but no verbal threat
2(d) Both verbal threat and physical contact
3(a) Involved only student offender(s)
3(b) Involving only employee offender(s)
3(c) Involving both student and employee offenders

Confirmation of Complaint/Incident of Discrimination and/or Harassment

Was this complaint confirmed as an incident of Discrimination and/or Harassment? *

If no, explain why below: *

If other selected, please enter action taken as the result of this incident:

Notes on Actions Taken

(Provide details below) *

Staff Members Involved in This Investigation

Name of Staff Member	Staff Member’s Title