Pleasant Valley
Community Schools
Pleasant Valley Community School District
Bullying and Harassment Reporting

Pleasant Valley Community School District is dedicated to ensuring a safe and supportive learning environment for all students. We recognize that in any school, the potential exists for bullying to occur. We take this potential seriously, and we have policies and procedures in place that ensure that each report of alleged bullying is investigated and acted upon by the school administration.

What is Bullying?

  • 1. Bullying is deliberate with the intentions to hurt someone.
  • 2. Bullying involves an imbalance of power with selected targets.
  • 3. Bullying is repeated and targeted behavior.

Individuals now have the ability to report alleged bullying and harassment incidents using the below Online Bullying Reporting Form, or by printing and completing the printable Bullying and Harassment Reporting Form, which may be delivered or sent to the Main Office of a Pleasant Valley Community School.

For more information and online links regarding bullying and harassment prevention, please feel free to visit our Bullying and Harassment Prevention Information Page.

Online Bullying and Harassment Reporting Form

First Name of Reporting Person:

Last Name of Reporting Person:

How Can We Contact You If Needed?:

Your Phone Number or E-mail Address:

School of Target Individual(s):*

Grade of Target Individual(s):

First and Last Name(s) of Target Individual(s):*

First and Last Name(s) of Harasser(s) or Bully(ies):*

Date of Incident:*

Time of Incident:*

Location of Incident:*

If "Other" Was Selected For Location Please Describe:

Person Was Bullied And/Or Harassed Because Of Their Actual Or Perceived (Check All That Apply):

 Age Physical or Mental Ability Socioeconomic Status Gender Identity Race
 National Origin/Ethnic Background Physical or Mental Disability Marital Status Sexual Orientation Other
 Physical Attributes Sex Familial Status Religion

If "Other" Was Selected Please Describe:

Person Was Bullied And/Or Harassed In The Following Ways (Check All That Apply):

 Electronic Communication Verbal
 Physical Social/Relational (Excluded From Group)
 Other

If "Other" Was Selected Please Describe:

Description Of The Incident:*
Please provide a detailed description of what happened and/or what was said. Include reference to evidence you may have including text messages, posts, pictures and etc.

Name Of Witnesses (If Any):

How Often Has This Issue Occured?:

Was This Issue Previously Reported?:*

If "Other" Was Selected Please Describe:

I agree that all the information is accurate and true to the best of my knowledge.*
 Yes

Administration Center

525 Belmont Road
Bettendorf, IA 52722

Phone: (563) 332-5550
E-mail: pvweb@pleasval.k12.ia.us
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