Bullying Report Form: Lombard Middle School

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CUSD #205 is committed to creating a safe, supportive, and positive environment for students to obtain a quality education. School 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, 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 administration. It is possible to remain anonymous, and it encourages bystanders of bullying incidents to report their observations so appropriate action can be taken.

Email *

Name of person making referral *

Date of incident *

YYYY

Time of incident

Time

First name of person being reported as target of bullying *

Last name of person being reported as target of bullying *

Additional name of potential victim (First, Last)

Additional name of potential victim (First Last)

Name of person(s) being reported as aggressor (bully) *

List names of persons who witnessed the bullying (Put none if there aren't any) *

Was the incident based on any of these characteristics? (Check all that apply)

Race

Sex

Pregnancy

Age

Mental disability

Marital Status

Color

Sexual Orientation

Religion

Parental Status

Nationality

Gender identity or expression

Ancestry

Physical disability

Homeless status

Associated with person/group with one or more of the above actual or perceived characteristics

Other

I do not know

Physical Appearance

Socioeconomic Status

Academic Status

Military Status/Unfavorable Military Discharge

Students were targeted for bulling in the following way(s) (check all that apply) *

Electronic devices (e.g., internet, Social media platforms, text, email, cyberbullying, etc.)

Written communication (e.g., handwritten notes, other written documents, email, etc.)2

Physical act or conduct (e.g., pushing, hitting, destruction of property, stalking, etc.)

Verbal act or conduct (e.g., rumors, lies, name-calling, using derogatory slurs, etc.)

Social (e.g., purposeful exclusion, causing psychological harm, etc.)

Items depicting implied hatred or prejudice were worn, possessed or displayed

Incident based on race or ethnicity

Incident based on sex

Incident based on religion

Other:

Required

Student(s) were targeted for bullying in the following place(s) (Check all that apply)

Classroom

Hallway

Cafeteria

Restroom

Gymnasium

Locker room

Extra curricular activity

Bus

Bus stop

School or related activity or event

Option 11

Other:

Please tell us about the incident in your own words. Use as much detail as possible-what time did the incident(s) take place, who witnessed it, what was said, and what types of interactions occurred (physical, written, social, electronic, etc.) *

I certify that the above information is true and accurate to the best of my knowledge. *

Yes

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