Bullying Incident Report

Please complete this form if you are being bullied or have witnessed someone being bullied at Worth School District 127.

Bullying, including cyber-bullying, is defined in 105 ILCS 5/27-23.7 as 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.
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Basic Information
Date of Incident
MM
/
DD
/
YYYY
I am a
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Name of person reporting (optional)
Phone Number (optional)
Role/Relationship to the Incident
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Description of What Happened (Please give a detailed description of the event including location, persons involved, and time it occurred.)

Type of Bullying (check all that apply):
Have any steps been taken already?  If yes, please explain.
What does the reporter hope will happen?
(e.g., mediation, discipline, monitoring, parent meeting)
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