Bullying/Harassment Reporting Form
This is a form to report alleged bullying/harassment that occurred during the current school year on school property, at a school-sponsored activity or event off school property, on a school bus, on the way to and/or from school, or on the internet-sent on or off school property; or that substantially disrupted the orderly operation of the school.
Bullying/harassment includes any intentional conduct, including verbal, physical or written conduct, or an intentional electronic communication, that creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities or performance or with a student’s physical or psychological well-being. Definitions for bullying, cyberbullying, harassment and intimidation are provided below:

Bullying - A pattern or behavior when a person repeatedly uses power in an intentional manner, including, verbal, physical or written conduct or intentional electronic communication against one or more students.

Cyberbullying - The use of electronic communication to harm or harass others in a deliberate, repeated and hostile manner.

Harassment - Includes actual or perceived negative actions that offend, ridicule or demean another individual with regard to race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, physical or mental ability, or disability.

Intimidation - Subjecting an individual to intentional action that seriously threatens and induces a sense of fear and/or inferiority.

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Today's date *
Person Reporting Incident
Name of person you are concerned about *
Name of offender *
Name(s) of witnesses *
Check the box(es) that apply: *
Date(s) of incident(s) *
Where did incident happen? *
Describe the incident.  Please include what the offender said and/or did. *
Is there any additional information you would like to provide?
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This form was created inside of Millstadt Community Consolidated School District #160. Report Abuse