EmailMe Form - Lennox Bullying Report Form

School Site *

Choose the site where the incident occurred.

Reporter *

Please tell us who you are.

Name (optional)

First Last

Please give your name. If you want to be notified of follow-up, you must provide your name.

Incident Information

Please complete the following to tell us about the incident.

Type of bullying: *

If you chose other, please describe here:

Victim *

Who was the person being harmed, bullied, harassed, or intimidated?

Instigator *

Who was the person bullying, harassing, intimidating, or causing harm?

Location of incident *

Where did the incident occur?

Date and Time *

MM / DD / YYYY HH : MM AM/PM

When did the incident occur?

Please describe the incident in as much detail as possible.

The incident *

Evidence available *

If there is any evidence available, please choose from the list. Choose as many options as you have available.

Other evidence

If you chose other, please indicate what that evidence is.

Contact Information

If you want to be notified of followup to the incident, or if you want to make yourself available in case we have questions, please provide some contact information.

Email

Phone

### - ### - ####

Address

Street Address City State / Province / Region Postal / Zip Code Country / Region