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"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 or out of school. 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:
  • Someone is threatening to beat you up in school, including when walking to or from school, when you get off the bus, while talking to you on your cell phone or while you are online.
  • Someone is taking something of yours without your permission.
  • Someone is spreading rumors about you or your family.
  • Someone is embarrassing you in front of others by either calling you names or doing something to you like hiding your books, pulling your seat out from under you, etc.
  • Someone is telling other kids not to talk to you or be friends with you.
  • 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.)

 

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:     


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© 2009 Mundelein High School District 120. All Rights Reserved|1350 W. Hawley Street, Mundelein, IL 60060|Phone: 847-949-2200|Fax: 847-949-4756