Report Bullying
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).
Please correct the following errors.
Which campus is this report for?
Lyndonville Elementary School
L.A. Webber Middle-High School
Who was being bullied, harassed, intimidated, or harmed?First Name
Last Name
Please indicate the grade level of the person being bullied, harassed, intimidated or harmed.
Pre-K
Kindergarten
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
Grade 11
Grade 12
If possible, please tell us the name(s) and ages of who was bullying, harassing, intimidating, or causing harm?
Are the names above students at LCS?
Yes
No
What date did the incident happen?
Where did the incident happen? (choose all that apply)
On school property
On a school bus
At a school-sponsored activity/event off school property
On the way to/from school
Other (Please specify)
Select the statement(s) that best describes what happened. (Choose all that apply)
Hitting, kicking, shoving, spitting, hair pulling, or throwing something
Getting another person to hit or harm the student
Teasing, name-calling, making critical remarks, or threatening, in person or by other means (including electronic methods)
Demeaning and making the student the victim of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Intimidating, extorting, or exploiting
Spreading harmful rumors or gossip
Other (Please specify)
Was this cyberbullying?
Yes
No
On which platform(s) did this occur?
Instagram
Snapchat
Twitter
Facebook
Other (Please specify)
Please provide the screen name, website, or other information about the cyberbullying.
How many times has this situation occurred?
1 to 2
3 to 5
More than 5
Have you reported this incident to an adult?
Yes
No
Describe what happened. Please give as much information as you can, including any witnesses.
Is there any additional information you would like to provide?
What would you like to submit?
Question
Comment
Suggestion
Concern
Compliment
Tell us who you are
(Select one or more)
Lyndonville Central School District Student
Lyndonville Central School District Parent/Guardian
Lyndonville Central School District Employee
Community Member
How can we contact you?
Please enter your name and at least one form of contact. If you leave this section blank, you will remain anonymous and we will be unable to follow up with you.
Name
Email
Phone e.g (123) 456-7890
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