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.)
Name (Optional):
Your answer
Phone Number and/or Email Address (Optional):
Your answer
I Am (choose one): *
INCIDENT INFORMATION:
Please give as much detail as possible in your description of the incident.
Name(s) of Student(s) you Feel Were Targets of Bullying: *
Your answer
Name of Student(s) Allegedly Bullying Other Student(s) : *
Your answer
Date of Incident: *
MM
/
DD
/
YYYY
Estimated Time of Incident: *
Time
:
Location of Incident: *
Your answer
Nature of Bullying Being Reported (check all that apply): *
Required
Please give any other details about the incident that you feel are important. *
Your answer
Did you personally witness the incident? *
Name(s) of Witnesses/Bystanders:
Your answer
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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