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Lynnville-Sully Bullying/Harassment Reporting Form
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?
L-S Elementary School
L-S Middle School
L-S High School
Person Reporting (First & Last Name)
Who is being bullied and/or harassed? (First & Last Name)
Where did the incident happen?
Off School Grounds
Who is doing the bullying or harassing?
What has happened? (Please be as detailed as possible)
How long has this been going on?
Witness/es name/s (if any)
What have you done about the problem? (What did you do/say?)
Have you talked to someone about this already?
Have not talked to anyone
Please list the names of individuals you have talked to about this.
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.)
I want someone to know
I want an adult to talk to the person who is doing the bullying/harassment.
I want an adult to help me and the person/s doing the harassing/bullying to solve the problem.
I want an adult to try to stop the bullying/harassment.
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This form was created inside of Lynnville-Sully Community Schools.