104.E(1) - Complaint Form

Date of complaint: __________________________________________________________

Name of Complainant: __________________________________________________________

Are you filling out this form for __________________________________________________________

yourself or someone else (please

identify the individual if you are __________________________________________________________

submitting on behalf of someone else):

Who or what entity do you __________________________________________________________

believe discriminated against,

harassed, or bullied you (or someone else)? __________________________________________________________

Date and place of alleged __________________________________________________________

incident(s):

__________________________________________________________

Names of any witnesses (if any): __________________________________________________________

In the space below, please describe what happened and why you believe that you or someone else has been discriminated against, harassed, or bullied. Please be as specific as possible and attach additional pages if necessary.

__________________________________________________________________________________________________

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

Signature: _____________________________________ Date: __________________________

I.C. Iowa Code                                      Description
Iowa Code § 216.9                                Unfair/Discriminatory Practices
Iowa Code § 280.28                              Harassment and Bullying Prohibited
Iowa Code § 280.3                                Education Program - Attendance Center Requirements

I.A.C. Iowa Administrative Code Description
281 I.A.C. 12.3 Administration

U.S.C. - United States Code                    Description
20 U.S.C. §§ 1221                                  Education - FERPA - General Provisions
29 U.S.C. §§ 794                                   Labor - Vocation Rehab Rights
42 U.S.C. §§ 12101                                Public Health - Equal Opportunity - Disabilities
42 U.S.C. §§ 2000d                                Public Health - Civil Rights - Federally Programs

U.S. Supreme Court Description
551 U.S. 393 Morse v. Frederick (2007)

Case Law Description
Morse v. Frederick 551 U.S. 393 (2007)

Cross References: 102 Equal Educational Opportunity
102-R(1) Equal Education Opportunity - Grievance Procedure
102-E(1) Equal Education Opportunity - Annual Notice of Nondiscrimination
102-E(2) Equal Education Opportunity - Continuous Notice of Nondiscrimination
102-E(3) Equal Education Opportunity - Notice of Section 504 Student and Parental Rights
102-E(4) Equal Education Opportunity - Discrimination Complaint Form
102-E(5) Equal Education Opportunity - Witness Disclosure Form
102-E(6) Equal Education Opportunity - Disposition of Complaint Form
401.01 Equal Employment Opportunity
402.03 Abuse of Students by School District Employees
404 Employee Conduct and Appearance
404-R(1) Employee Conduct and Appearance - Code of Professional Conduct and Ethics Regulation
404-R(2) Employee Conduct and Appearance - Code of Rights and Responsibilities Regulation
604.11 Appropriate Use of Online Learning Platforms
605.06 Internet - Appropriate Use
605.06-R(1) Internet - Appropriate Use - Regulation
605.06-E(1) Internet - Appropriate Use - Internet Access Permission Letter to Parents
605.06-E(2) Internet - Appropriate Use - Violation Notice
605.08 Artificial Intelligence in the Educational Environment
605.08-R(1) Artificial Intelligence in the Educational Environment - Regulation
713 Responsible Technology Use & Social Networking
713-R(1) Responsible Technology Use & Social Networking - Regulation

Approved: 9/17/2018, 9/18/2023, 11/18/2024, 9/15/2025
Reviewed: 8/15/2025
Revised: 8/15/2025

dawn.gibson.cm… Wed, 06/24/2026 - 20:18