LYNDONVILLE CENTRAL SCHOOL DISTRICT BULLYING REPORTING FORM

Directions:  Bullying and intimidation are serious and will not be tolerated. This is a form to report alleged bullying and intimidation that occurred on school property; at a school-sponsored event off school property; on a school bus; or on the way to and/or from school, in the current school.

If you are a student victim, or a close adult relative of a student victim, teacher, counselor or other staff member and wish to report an incident of alleged bullying, complete this form and it will be sent to the Principal of the appropriate grade level. Contact the school for additional information or assistance at any time.
 
According to LCS Policy #7552, bullying is defined as "a variety of negative acts carried out repeatedly over time. It involves a real or perceived imbalance of power, with a more powerful child or group attacking those who are less powerful." Bullying can take three forms:  physical, verbal, and psychological. The District also prohibits Internet bullying (also referred to as cyber-bullying).
Which campus is this report for?
Please indicate the grade level of the person being bullied, harassed, intimidated or harmed.
Are the names above students at LCS?
What date did the incident happen?
Where did the incident happen? (choose all that apply)
Select the statement(s) that best describes what happened. (Choose all that apply)
Was this cyberbullying?Question is mandatory
How many times has this situation occurred?
Have you reported this incident to an adult?
How can we contact you? To receive a personalized response, please enter your name and at least one method of contact. If you leave this section blank, then we will not be able to respond to your message. If you would like to receive a response but keep your identity hidden from us, enter your email address and select 'Hide your contact information from the district.'

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