NLMS Bullying, Harassment or Intimidation Reporting Form

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2025-2026

Today's Date *

YYYY

Name of student victim *

Age of student victim *

Grade of student victim *

6th Grade

7th Grade

8th Grade

Name(s) of alleged offender(s) (if known)

Alleged offenders school (if known)

Indian Valley Elementary School

Pinecrest School

Nichols Lawson Middle School

Sylacauga High School

Clear selection

Where did the incident occur (choose all that apply)? *

On school property

On school bus

At a school sponsored activity or event off school property

On the way to/from school

Other

Required

Choose the statement(s) that best describes what happened (choose all that apply) *

Any bullying, harassment, or intimidation that involves physical aggression

Getting another person to hit or harm the student

Teasing, name-calling, making critical remarks, or threatening, in person or by other means

Demeaning and making the victim of jokes

Making rude and/or threatening gestures

Excluding or rejecting the student

Intimidating (bullying), extorting, or exploiting

Spreading harmful rumors or gossip

Electronic communication (specify)

Other (specify below)

Required

If you chose Electronic communication or Other in the previous question, please specify.

What did the alleged offender(s) say or do? *

Do you have any information to share about why the bullying, harassment or intimidation occurred? *

Is there any additional information you would like to provide (ex. threats of suicide, legal issues, etc.)?

Person reporting incident contact number

Submit

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