Harassment/Bullying Report Form
Harassment and bullying are defined in Iowa Code section 280.28 as: 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, activities, or privileges provided by a school

"Trait or characteristic of the student" includes but is not limited to age, color, creed, national origin, race, religion, marital status, sex, sexual orientation, gender identity, physical attributes, physical or mental ability or disability, ancestry, political party preference, political belief, socioeconomic status, or familial status.

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Name of Targeted Student *
Today's Date *
Name of Person Making Report *
Email *
Relationship to Targeted Student *
Name of Student who prompted this report *
What type of bullying took place? *
When did the bullying take place? *
Is this the first time you have reported bullying? *
If no, how many times before have you reported bullying? To Whom? *
State what the bully (perpetrator) said/did: *
State what you or targeted student said/did: *
How has this impacted you or the targeted student? *
Who else was around who saw or hears this happen? *
What made you decide that you need to report this? *
Was there physical injury? *
Was the injury reported at school? *
If yes, to whom?
Additional Comments:
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