Home : MHS: Report Bullying
 

"Silence is Acceptance"

Bullying incident report form

The form below is provided for you to inform us about any situation or problem that you are having or know information about regarding being bullied or harassed. This can apply to you as a victim or an incident that you have witnessed. These situations can occur in school, out of school, through technology or electronic communication. Please provide as much information as you can so that the problem can be addressed directly.

The information will be sent to Dean Smigielski and Dean Thatcher, and if necessary, they will notify the appropriate personnel.


Examples of bullying/cyber-bullying:
  • Someone is threatening to beat you up either in person or through technology/electronic communication.
  • Someone is taking something of yours without your permission.
  • Someone is spreading rumors about you or your family, either in person or through technology/electronic communication
  • Someone is embarrassing you in front of others by either calling you names or doing something to you, either in person or through technology/electronic communication
  • Someone is telling other kids not to talk to you or be friends with you, either in person or through technology/electronic communication
  • Someone continues to shove into you in the halls and says it is always an accident.
  • Someone is sexually harassing you. (following you around, whistling at you, making comments about your body or doing something to your body, touching you inappropriately, etc.), either in person or through technology/electronic communication

 

False reporting of an incident is against state law and school policy.



  Indicates required field
I am a:     
Name (optional, but helpful):     
Address (optional):     
Email (optional):     
Phone (optional):     
Name of victim     
Grade of victim     
Name(s) of alleged offender(s):     
Grade(s) of alleged offender(s):     
Where did the incident happen:     




Date of incident:     
Time of incident (if known):     
Has this incident been reported to anyone yet?     
Who was incident reported to:     
Were there any witnesses?     
Names of witnesses:     
Describe what happened:     


Quicklinks

School Mailing List

Sign up to receive the latest information on community events, news and alerts!
 
© 2009 Mundelein High School District 120. All Rights Reserved|1350 W. Hawley Street, Mundelein, IL 60060|Phone: 847-949-2200|Fax: 847-949-4756