23-24  LSC Bullying, Harassment, or Intimidation & Sexual Abuse Reporting Form
The Bullying, Harassment or Intimidation Reporting Form should be used to report alleged incidents of bullying, harassment, or intimidation that occurred during the current school year on school property, at a school-sponsored activity or event off school property, on the way to and/or from school, or through personal mobile device on or off school property. School staff will address incidents that occur at school or have a connection or nexus back to the school setting that create a risk of harm to other students while they are at school or interfere with the educational environment.

If you are a student, the parent/guardian or a family member of a student, a school staff member, or a bystander and wish to report an incident of alleged bullying, cyberbullying, harassment, or intimidation, please complete this form. You may contact the school for additional information or assistance at any time. (Bullying, cyberbullying, harassment, and intimidation definitions are provided below.)

BULLYING —is unwanted, demeaning behavior among students that involves a real or perceived power imbalance. The behavior is
repeated, or is highly likely to be repeated, over time. In order to be considered bullying, the behavior must be intentional and include
1) An imbalance of power (students who bully use their physical, emotional, social, or academic power to control, exclude, or harm
others) and 2) Repetition (bullying behaviors happen more than once or are highly likely to be repeated based on evidence gathered).
CYBERBULLYING —is bullying transmitted by means of personal mobile devices through electronic communication that allows
individuals to view or share content. Cyberbullying includes sending, posting, or sharing personal or private information about someone
causing embarrassment or humiliation.
HARASSMENT —includes actual or perceived negative actions that offend, ridicule, or demean another student with regard to race,
ethnicity, national origin, immigration status, family/parental or marital status, sex, sexual orientation, gender identity, gender expression,
religion, ancestry, physical attributes, socioeconomic status, physical or mental ability, or disability.
INTIMIDATION —is any communication or action directed against another student that threatens or induces a sense of fear and/or
inferiority. Retaliation may be considered a form of intimidation.
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Email *
Your First and Last Name *
Phone Number *
Email Address *
Who is completing the form? *
Alleged Victim: First and Last Name *
Alleged Victim: Grade/Homeroom Teacher (if known)
Alleged Victim: Days Absent as a Result of Incident (if known)
Alleged Witness(es): First and Last Name *
Alleged Witness(es): Grade/Homeroom Teacher (if known)
Alleged Witness(es): LSC Student Y/N *
Alleged Offender: First and Last Name *
Alleged Offender: Grade/Homeroom Teacher (if known)
Alleged Offender: LSC Student Y/N *
On what date did the incident happen? *
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YYYY
Please add any other dates the incident happen if applicable.
Where did the incident happen? (Check all that apply) *
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If the incident happened on school property please identify below where.
Describe the incident including what the respondent said or didn't say. *
Why do you think the bullying, harassment or intimidation happened? *
Did a physical injury result from this incident? *
If there was a physical injury, do you think there will be permanent effects on the student victim?
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Was the complainant absent from school as a result of this incident? *
Did a psychological injury happen as a result of this incident? *
Is there any additional information you'd like to share?
By clicking below I understand that my electronic submission of this form and my electronic signature are intended to be, constitute, and are equivalent to my personal signature. *
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A copy of your responses will be emailed to the address you provided.
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