Bullying & Harassment Form

Form more information, see the Iowa Department of Education information on Anti-Bullying/Anti-Harassment.

Fields with an asterisk (*) are required.

Name(s) of person(s) who were bullied or harassed *
Student may have fought back. They don't have to be "innocent"
Role of person doing the bullying or harassment *
Name(s) of student(s) doing the harassment or bullying *
Where did the incident occur? *
Name(s) of witness(s) *
Maybe passive bystanders or supporters
Explain what happened as you saw it, or as it happened to you, or was described to you *
Please use as much detail as possible
How did you intervene? If you did not intervene, please describe your actions after the incident *
If you were not present, please describe your follow-up actions
To your knowledge, does this action follow a pattern of behavior? *
Has the agressor behaved this way before, or has the target previously reported bullying and/or harassment?
Please add any comments that may be relevant
Please let us know who you are *
Your Name: Person giving the report--Not Required