LCPS Bullying Report Form
Bullying is a serious issue and will not be tolerated. Use this form to report bullying that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; on the way to and/or from school; on social media or through text message, during the current school year.
REPORTER CONTACT INFORMATION:
Reports can be made anonymously. (Please note: Discipline decisions cannot be made solely on anonymous reports.)
Phone Number and/or Email Address (Optional):
I Am (choose one):
Please give as much detail as possible in your description of the incident.
Name(s) of Student(s) you Feel Were Targets of Bullying:
Name of Student(s) Allegedly Bullying Other Student(s) :
Date of Incident:
Estimated Time of Incident:
Location of Incident:
Nature of Bullying Being Reported (check all that apply):
Physical (Acts such as hitting, spitting, kicking, or damaging property)
Verbal (Saying mean, hurtful, or threatening things)
Social (Excluding from a group, telling peers not to talk to you or another student)
Emotional (Spreading mean rumors or lies about someone)
Cybler/Online (Occurred on website or social media, cell phone, email, or text message)
Please give any other details about the incident that you feel are important.
Did you personally witness the incident?
Name(s) of Witnesses/Bystanders:
STATEMENT OF BELIEF AND CONCERN:
I am submitting this form based on my belief that a student(s) bullied me or another person. I am reporting this because I am concerned and I want the situation to be better in the future.
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