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LCSD
Bullying Form
Monday, December 6, 2021
Lee County Schools
Bullying Form
Your Contact Information
Your Name (optional)
Your Email (optional)
Your Phone (optional)
Are you an LCS employee?
--Select--
Yes
No
May we contact you?
--Select--
Yes
No
Incident Information
School
--Select--
Guntown Middle School
Improvement Center
Mooreville Elementary School
Mooreville High School
Mooreville Middle School
Plantersville Middle School
Saltillo Elementary School
Saltillo High School
Saltillo Primary School
Shannon Elementary School
Shannon High School
Shannon Middle School
Shannon Primary School
Verona Elementary School
How long has this been going on?
--Select--
Days
Weeks
Months
Years
Grade
--Select--
Pre-K
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Did anyone witness this incident? If so, who?
Where did this incident occur?
--Select--
Bathroom
Bus
Cafeteria
Classroom
Computers
Gymnasium
Hallway
Library
Main Office
Nearby
Nowhere
Other
Outside
Outside Road
Parking Lot
School Office
Stairway
Street
Have any school staff been notified about this? If so, who?
Severity of Incident
--Select--
Minor
Moderate
Severe
Date of Incident
Time of Incident
Description (What happened?)
Behaviors
Cell Phone Message
Cyber Bullying
Damaging Property
Disability Comments
Exclusion/Leaving Out
Fighting
Homophobic Comments
Involving Friends/Peers
Name Calling/Insults
Racist Comments
Sexual Comments
Shoving/Hitting
Spitting
Spreading Rumors
Threats/Intimidation
Weapon Related
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