Stay away forms
DATING ABUSE AND SEXUAL VIOLENCE REQUEST FOR ACCOMMODATION
Name: __________________________ Grade: ________ Student ID: _____________________
Gender : _____ Date: _______ School: _____________________________________________
Please answer the following questions about the most recent or most serious incident:
What is the alleged perpetrator’s gender? ____________________________________________
Describe the relationship between you and the alleged perpetrator (perpetrator’ s name optional):
______________________________________________________________________________
Describe the incident:____________________________________________________________
______________________________________________________________________________
When and where did it happen? ____________________________________________________
Were there any witnesses? ____ yes _____no
If yes, who? ___________________________________________________________________
Is this the first incident? _____yes____ no
If no, how many times has it happened before? ______________________________________
Other information, including previous incidents or threats: ______________________________
______________________________________________________________________________
______________________________________________________________________________
What accommodation(s) requesting? Please check all that apply.
____Change of class seat assignment
____Change of locker assignment
____Change of lab group or work group
____Change of gym group
____Change of my class schedule
____Permission to leave class to see a counselor or social worker
____Private space for meeting with counselors and school officials regarding dating abuse or sexual assault issues ____Excused absence for classes missed due to dating abuse or sexual violence
____Makeup class work, including homework, quizzes, tests, and any other graded work, for classes missed due to
dating abuse, sexual violence, or threat thereof
____Alternative education plan
____School transfer
____Other (please specify): ______________________________________________________________
_________________________________________________________________________________
____I consent to notification of my parent or guardian that I am seeking accommodation under this policy
____I do not consent to notification of my parent or guardian that I am seeking accommodation under this policy
____At this time I consent to notification of my abuser that I am seeking accommodation under this policy
____At this time I do not consent to notification of my abuser that I am seeking accommodation under this policy
I certify that all statements made in this request for accommodation are true and complete. Any intentional misstatement of fact will subject me to appropriate discipline. I authorize school officials to disclose the information I provide only as necessary to respond to this request.
Signatures:
Student’s name: _________________________________________ Date: _________________
Student’s signature: _____________________________________________________________
School official receiving request: ____________________________ Date: _________________
School official signature: _________________________________________________________
Source:
Model Dating Abuse and Sexual Violence Policy
A Comprehensive Approach to Addressing Dating Abuse and Sexual Violence in New York City Schools
http://www.americanbar.org/content/dam/aba/migrated/domviol/pdfs/abuse_and_sexual_violence_policy_nyc.authcheckdam.pdf
Name: __________________________ Grade: ________ Student ID: _____________________
Gender : _____ Date: _______ School: _____________________________________________
Please answer the following questions about the most recent or most serious incident:
What is the alleged perpetrator’s gender? ____________________________________________
Describe the relationship between you and the alleged perpetrator (perpetrator’ s name optional):
______________________________________________________________________________
Describe the incident:____________________________________________________________
______________________________________________________________________________
When and where did it happen? ____________________________________________________
Were there any witnesses? ____ yes _____no
If yes, who? ___________________________________________________________________
Is this the first incident? _____yes____ no
If no, how many times has it happened before? ______________________________________
Other information, including previous incidents or threats: ______________________________
______________________________________________________________________________
______________________________________________________________________________
What accommodation(s) requesting? Please check all that apply.
____Change of class seat assignment
____Change of locker assignment
____Change of lab group or work group
____Change of gym group
____Change of my class schedule
____Permission to leave class to see a counselor or social worker
____Private space for meeting with counselors and school officials regarding dating abuse or sexual assault issues ____Excused absence for classes missed due to dating abuse or sexual violence
____Makeup class work, including homework, quizzes, tests, and any other graded work, for classes missed due to
dating abuse, sexual violence, or threat thereof
____Alternative education plan
____School transfer
____Other (please specify): ______________________________________________________________
_________________________________________________________________________________
____I consent to notification of my parent or guardian that I am seeking accommodation under this policy
____I do not consent to notification of my parent or guardian that I am seeking accommodation under this policy
____At this time I consent to notification of my abuser that I am seeking accommodation under this policy
____At this time I do not consent to notification of my abuser that I am seeking accommodation under this policy
I certify that all statements made in this request for accommodation are true and complete. Any intentional misstatement of fact will subject me to appropriate discipline. I authorize school officials to disclose the information I provide only as necessary to respond to this request.
Signatures:
Student’s name: _________________________________________ Date: _________________
Student’s signature: _____________________________________________________________
School official receiving request: ____________________________ Date: _________________
School official signature: _________________________________________________________
Source:
Model Dating Abuse and Sexual Violence Policy
A Comprehensive Approach to Addressing Dating Abuse and Sexual Violence in New York City Schools
http://www.americanbar.org/content/dam/aba/migrated/domviol/pdfs/abuse_and_sexual_violence_policy_nyc.authcheckdam.pdf