Bullying Reporting Form
IF YOU ARE IN IMMEDIATE DANGER, CALL 911.
Leverett's Chapel ISD is committed to providing a safe, comfortable learning environment for all students. Bullying incidents can be reported directly to a trusted staff member at your school. This online form may also be used by Leverett's Chapel students to report being bullied or by someone witnessing a student being bullied.
Date of Incident:
Location where incident occurred (optional)
Cyber ( Facebook, Twitter, Snap Chat, Etc.)
Name of victim(s):
Name of student(s) bullying:
Reporting person name (optional)
Phone Contact (optional)
Select which apply to you (optional)
Please Check All That Apply
Physical harm or threatening physical harm
Obtaining money or another object of value from an unwilling person, or forcing an individual to act
Making ethnic, racial, religious, or other harassing slurs
Verbal abuse or derogatory or offensive remarks addressed to others
Damaging or vandalizing property of other students
Conduct that constitutes sexual harassment or sexual abuse
Dating violence, meaning the intentional use of physical, sexual, verbal, or emotional abuse
Additional Comments (optional)
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