Date
Date of initial complaint
Name of Complainant (include whether the Complainant is a student or employee)
Date and place of alleged incident(s)
Name of Respondent ((include whether the Respondent is a student or employee)

 

Nature of discrimination, harassment, or bullying alleged (check all that apply)
Age Physical Attribute Sex
Disability Physical/Mental Ability Sexual Orientation
Familial Status Political Belief Socio‐economic Background
Gender Identity Political Party Preference Other – Please Specify:
National Origin/Ethnic Background/Ancestry Religion/Creed
Method of Bullying/harassment (check all that apply)
Electronic Communication Written Communication (e.g. cyber) Verbal
Physical Social/Relational (ostracizing, exclusion) Other – Please Specify

 

 

Location of Incident
Bus Hallway Classroom
Locker room Gym Cafeteria
Bathroom At lockers Playground
Extracurricular activity (on/off campus) Other – Please Specify

 

 

Summary of investigation

If the Iowa Anti-Bullying/Harassment Law was violated, please check all the reasons that apply below
Was violated because conduct places the student in reasonable fear or harm to the student’s person or property.
Was violated because conduct has a substantially detrimental effect on the student’s physical or mental health.
Was violated because conduct has the effect of substantially interfering with the student’s academic
performance.
Was violated because the conduct 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.
If the Iowa Anti-Bullying/Harassment Law was not violated, please check the box indicating that another
law, school policy or rule was violated OR check the box indicating that no law school policy or rule was
violated
Was NOT violated nor was any other law/school policy/rule violated
Was NOT violated but another law/school policy/rule was violated. (such as code of conduct)
Consequences are in place

Date Investigation was completed: ________________________________

I agree that all of the information on this form is accurate and true to the best of my knowledge.

Signature of Investigator __________________________________________ Date ________________________________
Signature of Bldg. Principal (if different from investigator) __________________________________________  Date  ________________________________

Copies: Parent/Guardian___ Superintendent___ Alleged Harasser/Bully___ File___


****For Department of Education data collection purposes only**** Please check all of the following consequences/remedial actions that apply
Verbal Warning Written Warning Parent(s)/Guardian(s) notified
Parent(s) or guardian conference Signed agreement to avoid
further incidents
Support from Counselor
(follow up)
Restricted privileges (includes
loss of recess, isolated lunch extra
curricular activities, etc)
Individual Behavior Plan
focused on bullying behaviors
Detention (includes Saturday
School)
Specialized seating assignment SRO Referral Law Enforcement involved
In School Suspension
Number of days
Suspension or expulsion
Number of days
Bus Suspension
Number of days
Community service Referral to Internal team No consequences warranted
Student conference with administrator Other – Please Specify: