District 205 Bullying Report Form
District 205 is committed to ensuring a safe, supportive, and positive environment for students to obtain a quality education. School-related incidents involving bullying are taken very seriously. When these incidents are reported, support services can be provided to all students involved.

As stated in the Code of Student Conduct Book, bullying is defined as any severe or pervasive physical or verbal act or conduct, including communications made in writing or electronically, directed toward a student that has or can be reasonably predicted to have the effect of one or more of the following:
1. Placing the student in reasonable fear of harm to the student's person or property.
2. Causing a substantially detrimental effect on the student's physical or mental health.
3. Substantially interfering with the student's academic performance.
4, Substantially interfering with the student's ability to participate in or benefit from the services, activities, or privileges provided by a school.

This form has been created to help provide a safe means of reporting an incident of bullying to school personnel. It is designed to encourage anyone who is a witness or subject of bullying incidents to report their observations so appropriate action can be taken. Victims of bullying and witnesses are also encouraged to use this form, as well as report the incident directly to the staff.

While administrators need your name to conduct a full investigation, your identity will remain confidential.

Your Name *
I understand that I will be interviewed when this incident is investigated by District 205 staff and that my name will be kept confidential.
Your answer
Who is being bullied? *
You are a *
How can you be contacted about this incident? *
Provide an email address or phone number to help us follow up with you on this matter. If you choose not to provide contact information, our ability to investigate may be very limited.
Your answer
Which school should be notified to help you with this incident? *
Date of Incident *
MM
/
DD
/
YYYY
Students were targeted for bullying in the following way(s) *
Check all that apply
Required
When did this happen?
Describe the Incident.
Your answer
Names of Witnesses, if any
Your answer
What Happens Next?
1. If you feel you are in immediate danger, contact the authorities as soon as possible.
2. After submitting this form, you may be contacted by administration, counselors/outreach workers, or police.
3. School personnel will investigate and may require addition information from the individual submitting the report.
4. All bullying incidents will be handled according to the Student Code of Conduct, p. 10-11, found at www.galesburg205.org/board/codes_of_conduct/
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