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Lynnville-Sully Bullying/Harassment Reporting Form
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Iowa Code section 280.28 defines harassment and bullying as:
Any electronic, written, verbal, or physical act or conduct toward a student which is based on any actual or perceived trait or characteristic of the student and which creates an objectively hostile school environment that meets one or more of the following conditions:
• Places the student in reasonable fear of harm to the student's person or property.
• Has a substantially detrimental effect on the student's physical or mental health.
• Has the effect of substantially interfering with a student's academic performance.
• Has the effect of substantially interfering with the student's ability to participate in or benefit from the services, activities, or privileges provided by a school.
Which school do you attend? *
Person Reporting (First & Last Name)
Your answer
Who is being bullied and/or harassed? (First & Last Name) *
Your answer
Where did the incident happen? *
Who is doing the bullying or harassing? *
Your answer
What has happened? (Please be as detailed as possible) *
Your answer
How long has this been going on? *
Your answer
Witness/es name/s (if any)
Your answer
What have you done about the problem? (What did you do/say?) *
Your answer
Have you talked to someone about this already? *
Please list the names of individuals you have talked to about this.
Your answer
What do you want to happen after the school receives your information? *(NOTE: The school will determine the best course of action based on your selection.) *
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