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