Report a Bully

The Lowndes County School District strives to provide a safe, secure, and respectful learning environment for all students in school buildings and on school grounds, on school busses, and at school-sponsored activities. This confidential form is submitted to administration. If this is an emergency, please contact the appropriate school/district personnel.
School*
Date of Incident*

MonthDayYear
Date
At what point during the day did the incident occur?*

At the bus stopOn the way to schoolBefore classes beganDuring classBetween classesDuring dismissalOn the way home from schoolDuring after-school activitiesOther
Where did the incident occur?*

CafeteriaClassroomHallwayLibraryLocker RoomGymnasiumRestroomPlaygroundBusOther
How many times has this situation occurred?*

This is the first timeOne other timeOnce a monthOnce a weekEvery day
Have you reported this incident to an adult?*

YesNo
Please share the name of the person responsible for bullying/ harassing, intimidating, or causing harm. Include first name, last name, and grade, if known.*
Please share the name of the person being bullied harassed, intimidated, or harmed. Include first name, last name, and grade, if known. (This is optional for anonymity.)
Please share your name if you are willing to do so. (This is optional for anonymity.)
Please share the name of any witnesses. Include first name, last name, and grade, if known.
Describe what occurred, as specifically as possible.*

0/1500
Please select:*

I am a StudentI am a ParentI am a Faculty/Staff MemberI am an AdministratorI am a VolunteerOther
If you would like someone to contact you, please share your phone number.
Building (if different than main building)
Room Number (if applicable)
Should be Empty: