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Bullying/Harassment Concern
Bettendorf High School takes seriously the responsibility for providing a safe and supportive school environment for all students. Any student experiencing mistreatment of any kind should seek the assistance of an administrator, nurse, security or their school counselor. Situations of mistreatment often stem from interpersonal conflicts which can be resolved with the support of staff; however, in some instances, the mistreatment is intentional, persistent, unwelcome, harmful, pervasive and interferes with the school experience of the targeted student. This is unacceptable. Completing this form assists staff in ending the confirmed bullying/harassment toward the targeted student or intervening to resolve interpersonal conflicts or mistreatment of students. Thank you in advance for providing pertinent, honest details and for submitting this form.
Harassment and bullying shall be construed to mean 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,
or privileges provided by the school.
Iowa Code Section 280.28

This form is ideal for reporting a matter during non-school hours or on weekends; however, it does not replace the need to report a matter/situation to school personnel during the school day or at school sponsored events. If students feel threatened or concerned for self-safety, they should go immediately to student services, main office of security to report the situation.
First Name of Person Reporting: *
Your answer
Last Name of Person Reporting: *
Your answer
How may we contact you (if you are not a BHS student)?:
Your Phone number or Email (if you are not a BHS student):
Your answer
First and Last Name of Targeted Individual (if more than one, please submit separate form) *
Your answer
Grade of Targeted Individual(s): *
Whom do you believe has violated the district bullying policy?: *
Your answer
Why do you believe this happened?: *
Your answer
Date of Incident: *
MM
/
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/
YYYY
Time of Incident: *
Time
:
Location of Incident: *
Your answer
Description of Incident: *
Please provide a detailed description of what happened and/or what was said/done. Include reference to evidence you may have including text messages, posts, pictures, etc.
Your answer
Name of Witness(es) (If any): *
Your answer
How Often Has This Issue Occurred?: *
Your answer
Was This Issue Previously Reported? : *
If Yes Above, to Whom Was it Reported?
Your answer
Last Name of Targeted Student Counselor *
Last name of student determines counselor: (A-D) Harksen, (E-J) Jansen, (K-O) Schalk, (P-S) Strodtman, (T-Z) Cole
I agree that all the information is accurate and true to the best of my knowledge. *
Required
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