OCSD Anti-Bullying/Anti-Harassment/Anti-Discrimination Complaint Form
The Ottumwa Community School District believes that bullying, harassment, or intimidation is serious and will not be tolerated. In order for the district to take action the incident must be reported. The reporting of incidents is currently available to students and staff at designated school locations and with any district employee. Many student incidents are reported at home to parents and these are never documented with the school district.   Policy 104: Anti-Bullying/Harassment Policy addresses our processes and procedures.

For the purposes of OCSD policy, the defined words shall have the following meaning: 
“Electronic” means any communication involving the transmission of information by wire, radio, optic cable, electromagnetic, or other similar means. “Electronic” includes but is not limited to communication via electronic mail, internet-based communications, pager service, cell phones, and electronic text messaging.

 “Harassment” and “bullying” mean any repeated and targeted electronic, written, verbal, or physical act or other ongoing conduct toward an individual that creates an objectively hostile school environment that meets one or more of the following conditions: 
1. Places the individual in reasonable fear of harm to the individual’s person or property. 
2. Has a substantial detrimental effect on the individual’s physical or mental health. 
3. Has the effect of substantially interfering with the individual’s academic or career performance. Has the  effect of substantially interfering with the individual’s ability to participate in or benefit from the services, activities, or privileges provided by a school. 

OCSD has created this online form that can be filled out at any time to help students and staff who are targets of bullying, harassment, or intimidation. This form is to report alleged bullying, harassment, or intimidation that occurred on school property; at a school sponsored activity or event off school property; on a school bus; or on the way to and/or from school. If you are a student or staff target, the parent/guardian of a student target, or a close adult relative of a student target, or a school staff member and wish to report an incident of alleged bullying, harassment, or intimidation please complete this form. Please answer these questions as honestly and specifically as you can. The situation will be handled as confidentially as possible.

 *The Ottumwa Community School District is committed to providing all students, employees, and volunteers with a safe and civil school environment in which all members of the school community are treated with dignity and respect. Bullying and/or harassing behavior can seriously disrupt the ability of school employees to maintain a safe and civil environment, and the ability of students to learn and succeed.   

Non-Discrimination Statement
It is the policy of the Ottumwa Community School District not to discriminate on the basis of race, color, national origin, sex, disability, religion, creed, age (for employment), marital status (for programs), sexual orientation, gender identity and socioeconomic status (for programs) in its educational programs and its employment practices. There is a grievance procedure for processing complaints of discrimination. If you have questions or a grievance related to this policy, please contact the district’s Equity Coordinator, Maria Lantz, Director of Curriculum and Instruction, 115 N Ferry Street, Ottumwa, IA 52501, Telephone: (641) 684-6597, Email: (maria.lantz@ottumwaschools.com); or the Director of the Office for Civil Rights U.S. Department of Education, Citigroup Center, 500 W. Madison Street, Suite 1475, Chicago, IL 60661-7204, Telephone: (312) 730-1560 Facsimile: (312) 730-1576, Email: OCR.Chicago@ed.gov.
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First Name of complainant  *
Last Name of complainant 
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School
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Email of complainant
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Position of complainant
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Name of targeted individual
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Relationship to targeted individual
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Date of complaint
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Name of alleged individual
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Date and place of incident or incidents
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Description of the misconduct
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Nature of Harassment and/or Bullying:
 “Harassment” and “bullying” mean any repeated and targeted electronic, written, verbal, or physical act or other ongoing conduct toward an individual that creates an objectively hostile school environment that meets one or more of the following conditions: 
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Name of witnesses (if any)
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Evidence of harassment, bullying, or discrimination (i.e. letters, photos, etc.)
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Any other information
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I agree that all of the information on this form is accurate and true to the best of my knowledge.
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Your typed name indicates all information is accurate
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Today's Date
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