Bullying Reporting Form

Illinois law and Springfield Public School District 186 Board of Education Policy require schools to respond to all reports of alleged bullying. District 186 takes all reports of bullying seriously. 

Bullying and forms of harassment diminish a student’s ability to learn and the school’s ability to educate.  Preventing students from engaging in these disruptive behaviors and providing all students equal access to a safe, non-hostile learning environment are important goals of each school and of District 186. 

Definition of Bullying: Bullying includes cyber-bullying (bullying through the use of technology or any electronic communication) and means 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 at school. 

(See the Illinois School Code 105 ILCS 5/27-23.7 and Springfield Public Schools Student and Family Handbook) 


When a perceived bullying event occurs, please notify the building principal or his/her designee of the incident. A point person will be assigned to:

 • Take steps to complete the investigation;

 • Take into consideration additional information about the bullying received during the course of the investigation; 

• Develop a plan of action that is to be shared with the student(s) and family members of all involved; • Modify the plan as needed; and 

• Follow up with the student(s) and family members at an agreed upon timeframe. 


Please complete the Bullying Incident Reporting Form on the next page to report incidents involving students: 

• During any school-sponsored education program or activity

• While on school property, school buses or other school vehicles 

• At designated school bus stops 

• Traveling to/from school 

• At school-sponsored or school-sanctioned events or activities 

• Through the transmission of information from any computer, network, or other similar electronic equipment.



Email *
I have read the above information and have a clear understanding what bullying is. *
Required
Name of the Person Completing Report 
Name of School  *
Date of Incident 
MM
/
DD
/
YYYY
Time 
Time
:
Name of Target(s): *
Name of Aggressive Student(s)
Name(s) of Witness(es)/ Bystander(s)
Reported to School by (Check all that apply) *
Required
Name of the reporter
Location of Incident (Check all that apply): *
Required
When did the incident happen? (Check all that apply): *
Required
Specific Location
Describe the incident(s), including what the alleged aggressor(s) said or did and the harm. Please include/attach any evidence you might have *
Type of incident: (Check only if applicable)
Other 
Physical  (Check all that apply) 
Social (Check all that apply) 
Unlawful (Check all that apply) 
Verbal (Check all that apply)
The Aggressive Act was Related to: (check all that are applicable)
Did anyone get injured? *
Required
Type of injury, if known
Did you report this incident to Law Enforcement? *
Required
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