Report Bullying

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If you are reporting an incident of bullying that occured at a bus stop, please provide the location of the bus stop and the bus number, if known.

When reporting cyberbullying, please provide as much information as possible. Include type (Phone text messages, Social Network, Blogs...) For social networks please provide the page owner, if known.

If you are reporting an incident of bullying that occured in a school parking lot, please provide which parking lot and a descriptions of any cars you might have seen the bully, the victim, or witnesses get into. Also, please indicate if it appears the victim was forced into a car.

The School District of Escambia County
School Violence Reporting System
Report Teen Dating Violence

Is this report being given directly to a School District Employee?	Yes No
If yes, Name of Person Receiving Report:

* Indicates required field

Elementary School
Middle School
High School
Special Center
Unknown

*Select School:

select

Your Name (Optional):

First Name:

Last Name:

Who are you:

Concerned Citizen Parent Staff Student

Your Contact Information (Optional):

Address:

City:

State:

Zip Code:

Primary Phone Number:

Alternate Phone Number:

*Victim(s):

*Perpetrator:

*Describe the incident: (who, what, when, where)

*List all witness(es):

Where did this incident take place? (select all that apply)

Bathroom

Cyberbullying

Parking Lot

Bus Stop

Front of School

P.E. Fields

Cafeteria

Hallways

P. E. Locker Rooms

Classroom

Library

Playground

Common Areas

Lockers

School Bus

Other Location:

*How often has the bullying behavior occured?

select

First Time
2 Times
3 Times
4 Times
5 or More Times

Have you reported the bullying incident to anyone?

Yes No

If yes, to whom did you report the incident?

Version: 1.5