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
2. Causing a substantially detrimental effect on the student’s or students’ physical or mental
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.
I am a....
Please check the appropriate box
Person Being Bullied
Please list the name and grade of the person being bullied
Name of the Offender
Please list the name of the person causing the incident
Date of the Incident
Please mark the date the incident occurred.
Type of Bullying
Please list the type(s) of bullying that have occurred.
Physical- Hurting someone's body or possessions
Verbal- Saying or writing mean things
Social- Hurting someone's reputation or relationships
Cyberbullying- Willful or repeated harm through one's computer, cellphone or other electronic device
Where did the incident occur?
Please mark the place(s) where the bullying happened.
School related activity or event
Description of the Events
Please provide a detailed description of the events. Tell the whole story including location, date, and time of event.
Did you witness the bullying?
Would you be willing to talk with school staff about the incident?
Please list other students or staff that may have witnessed the incident.
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.).
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This form was created inside of Woodford County Special Education Association.