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
Student to Student
Student to Staff
Staff to student
Staff to Staff
Date and time of incident
Location of incident
Name of alleged harasser or bully:
Name of target of harassment or bullying:
Nature of incident (check all that apply)
Physical (hitting, kicking, pushing, tripping, pinching, etc)
Verbal (name calling, insults, teasing, intimidation, homophobic or racist remarks, etc)
Social/Relational (spreading rumors, embarrassing jokes, excluding, negative gestures/looks, damaging someone's reputation, etc)
Sexual (unwelcome/inappropriate sexual advances, remarks, rumors, gestures, contact, etc)
Cyber (occurred online and/or on social media)
Vandalism (damage to property)
Subject of harassment/bullying incident (check all that apply):
National Origin/Ethnic Background/Ancestry
Description of incident:
Name of witnesses (if any)
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.
Contact information (email or phone number):
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