Bullying Incident Form

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If you believe you have witnessed a bullying event on Herscher CUSD #2 property, please let us know. Please know that reports can be submitted anonymously. We appreciate your help as we better address this issue.

District property where incident was witnessed: *

Bonfield Grade School

Herscher Intermediate School

Limestone Middle School

Herscher High School

Please indicate the seriousness of this incident per scale below: *

1. Minor

2. Minor-Moderate

3. Moderate

4. Moderate-Severe

5. Severe

Please check all that apply: *

I was directly involved in this incident.

I observed this incident

I heard about this incident. (If checked, please also check 'Other' and identify from whom.)

Other:

Required

When did this incident occur? (Include date and time) *

To your knowledge, has it happened before? *

No.

Yes. (If yes, please also check 'Other' and explain.)

Other:

Required

Who was involved? Include the names of those directly involved and any bystanders/witnesses: *

Briefly describe the situation: *

To your knowledge, has there been any intervention? *

Yes (If yes, please also check 'Other' and describe.)

Maybe

Other:

Required

Reported by: *

Submitting Anonymously

If you would like to sign this report, please click 'Other' and enter your name.

Other:

Date Submitted:

YYYY

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