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
