Central Bullying/Harassment Report
The Central Community School District is committed to providing all students and staff with a safe environment in which all members of the school community are treated in a caring manner, as defined by our PBIS expectations: Caring Commitment and Safety.
Bullying/harassment does not allow students or staff to feel safe. Bullying, as defined by Iowa law, must fit these three criteria: aggressive, repeated, and have an imbalance of power. It may be electronic, written, verbal, or a physical behavior that includes
*fear of harm to self or property
*has a negative effect on physical or mental health
*has a negative effect on academic performance
*may interfere with participation on school activities or events.
If you feel that you have been bullied, please complete this form immediately.
The counselor will review it and respond to you within 24 hours.
I am a: *
Type of Incident *
Date and time of incident *
Your answer
Location of incident *
Your answer
Name of alleged harasser or bully: *
Your answer
Name of target of harassment or bullying: *
Your answer
Nature of incident (check all that apply) *
Subject of harassment/bullying incident (check all that apply):
Description of incident: *
Your answer
Name of witnesses (if any)
Your answer
Your name: *
By placing my name (first, last) in this box, I agree that all of the information on this form is accurate and true to the best of my knowledge.
Your answer
Contact information (email or phone number):
Your answer
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