District 128 - Harassment Reporting Form (Racial, Sexual or Gender-Based)

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No person, including a School District employee or agent, or student, shall harass, intimidate or bully a student on the basis of actual or perceived: race; color; national origin; military status; unfavorable discharge status from military service; sex; sexual orientation; gender identity; gender-related identity or expression; ancestry; age; religion; physical or mental disability; order of protection status; status as homeless; actual or potential marital or parental status, including pregnancy; association with a person or group with one or more of the aforementioned actual or perceived characteristics; or any other distinguishing characteristic.

Board Policy 7:20 strictly prohibits harassment of students. If you are the victim of or witness any type of harassment, it can be report to school administration or by utilizing this form

Location of Incident

Libertyville High School

Vernon Hills High School

Transition Pathways

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Name

E-mail Address

Telephone Number

I am a: (Check the appropriate box)

Student

Parent/Guardian of a student

Close adult relative of a student

School Staff

Bystander

Name of alleged student victim (if known)

Name of alleged offender(s) (if known)

Date of Incident

YYYY

Time of Incident

Time

Where did this incident happen?

On school property

On a school bus

At a school-sponsored activity or event off school property

On the way to/from school

Internet

Other

Describe what happened

Has this incident been reported to anyone yet?

Yes

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Who was the incident reported to?

Were there any witnesses?

Yes

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Names of witnesses

Submit

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