Liberty Independent School District: Bullying Incident Form
Bullying, Discrimination, Harassment, Retaliation
If this is an emergency, call 911. This report does not provide emergency services. This report is only used to notify school administration. You may also go directly to any school official (teacher, counselor, principal, etc.) to get help.

Please fill in all the information you can to help us stop the bully. Please try to give us a name or nickname. Do the best you can to remember the date and time. Be sure to identify the school you are from so we can direct your information effectively.

List the name(s) of the student(s) accused of bullying, discrimination, harassment, or retaliation:
Your answer
Relationship between you and the accused student:
Your answer
Describe the incident:
Your answer
When did this occur?
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DD
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YYYY
Time
:
Where did the incident occur?
Your answer
Were there any witnesses? If yes, please provide the names of the witnesses.
Your answer
Have there been any previous incidents involving the accused student? If yes, please explain:
Your answer
Other information, including previous incidents or threats:
Your answer
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