MGS Bullying Report Form
Metamora Grade School is committed to creating a safe and supportive learning environment for all students. School incidents involving bullying are taken very seriously at MGS. 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.
The Illinois legislature defines bullying as meaning: any severe or pervasive physical or verbal act or conduct, including communications made in writing or electronically, directed toward a student or students that has or can be reasonably predicted to have the effect of one or more of the following:
1. Placing the student or students in reasonable fear of harm to the student’s or students’ person
or property;
2. Causing a substantially detrimental effect on the student’s or students’ physical or mental
health;
3. Substantially interfering with the student’s or students’ academic performance; or
4. Substantially interfering with the student’s or students’ 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 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 MGS.

Thank you for taking the time to complete this form. MGS 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 and grade of the person being bullied
Your answer
Name of the Offender *
Please list the name of the person causing the incident
Your answer
Date of the Incident
Please mark the date the incident occurred.
MM
/
DD
/
YYYY
Type of Bullying *
Please list the type(s) of bullying that have occurred.
Required
Where did the incident occur? *
Please mark the place(s) where the bullying happened.
Required
Description of the 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?
Would you be willing to talk with school staff about the incident? *
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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