MTHS Bullying Report Form
Metamora Township High School is committed to creating a safe and supportive learning environment for all students. School incidents involving bullying are taken seriously at MTHS. When these incidents are reported, support services can be provided to all students involved. This includes the student being bullied, the offender, or a bystander.

Students cannot make verbal and/or implied threats to teachers/staff or other students. Statements, actions or digital communication that can alarm, disturb, harm, or interfere with the orderly operation of the school will not be tolerated. The district board of education prohibits acts of harassment, intimidation or bullying of a student. The district board of education has determined that a safe and civil environment in school is necessary for students to learn and achieve high academic standards; harassment, intimidation or bullying, like other disruptive or violent behaviors, is conduct that disrupts both a student's ability to learn and a school's ability to educate its students in a safe and disciplined environment.

This form has been created to help provide a safe means of reporting an incident of bullying to school personnel. It is designed to remain anonymous and it is encouraged that bystanders of bullying incidents report their observations so appropriate action can be taken. Victims of bullying are also encouraged to use this form as well as reporting the incident directly to the staff at MTHS.

A reprisal or retaliation against any person who reports an act of bullying is prohibited. A student's act of reprisal or retaliation will be treated as bullying for purposes of determining any consequences or other appropriate remedial actions.

A student will not be punished for reporting bullying or supplying information, even if the school's investigation concludes that no bullying occurred. However, knowingly making a false accusation or providing knowingly false information will be treated as bullying for purposes of determining any consequences or other appropriate remedial actions.

Thank you for taking the time to complete this form. MTHS appreciates your help in maintaining a safe environment for our students.

Your Name (Optional)
Name of the person reporting the bullying incident.
Your answer
I am a . . .
Please check the appropriate box.
Required
Person Being Bullied
Please list the name of the person being bullied.
Your answer
Name of the Offender
Please list the name of the person responsible for the incident.
Your answer
Date
Date of form submission.
MM
/
DD
/
YYYY
Type of Bullying
Please check the type(s) of bullying that has occurred.
Required
Description of Events
Please provide a detailed description of the events. Tell the whole story including location, date, and time of event.
Your answer
Bullying Witness
Did you witness the bullying?
Required
Other Witnesses
Please list other students or staff that may have witnessed the incident.
Your answer
How long has the bullying been going on?
Please report whether this is the first time the bullying has occurred or if it has been going on for a longer period of time (days, weeks, etc.)
Your answer
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