Central School District 51 Bullying Report Form
Central SD 51 is committed to creating a safe, supportive and positive environment for students. Central 51 takes bullying seriously and, when they are reported, incidents of bullying are addressed by the administration and our support staff.

As stated in the Central Handbook, bullying is considered engaging in hazing or any kind of aggressive behavior that does physical or psychological harm to a staff person or another student or encouraging other students to engage in such behavior. Prohibited conduct specifically includes, without limitation, any use of violence, intimidation, force, noise, coercion, threats, stalking, harassment, sexual harassment, public humiliation, theft or destruction of property, retaliation, hazing, bullying using a school computer or a school computer network or other comparable conduct.

This form has been created to 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 and witnesses are also encouraged to use this form and to also report the incident directly to Central 51 staff.

Thank you for taking the time to complete this form. We appreciate your help in maintaining a safe environment for our students and staff.

Your Name (Optional)
Your answer
Date *
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You are a *
Indicate here if you prefer to remain anonymous *
Are you the target of the bullying or school violence you are reporting? *
Date of Incident *
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DD
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Time of Incident *
Time
:
Person Being Bullied? *
Your answer
Name of offender (Person bullying someone) *
Your answer
Did you witness the bullying? *
Other Witnesses *
Your answer
How long has the bullying been going on? *
Your answer
Was the incident based on any of these characteristics? (Check all that apply) *
Required
If you answered the previous question as "other" please explain
Your answer
Student(s) were targeted for bullying in the following place(s): Check all that apply *
Required
If you answered the previous question as "other" please explain
Your answer
Please tell us about the incident in your own words. Use as much detail as possible--what time did the incident(s) take place, who witnessed it, what was said, what types of interactions occurred (physical, written, social, electronic, etc. ) *
Your answer
The above information is true and accurate to the best of my knowledge *
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