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.

Harassment on the basis of age, color, creed, national origin, race, religion, marital status, sex, sexual orientation, gender identity, physical attributes, or disability means conduct of a verbal or physical nature that is designed to unreasonably embarrass, distress, agitate, disturb or trouble students when such conduct has the purpose or effect of unreasonably interfering with a student's performance or creating an intimidating, offensive or hostile learning environment. Bullying is when a stronger, more powerful person hurts or frightens a smaller weaker person, on purpose, again and again.

We have 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.

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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Nature of bullying, harassment or discrimination
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Description of the misconduct
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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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