Lucas County Sheriff's Office
Anti-Bullying Initiative
Information Fact Sheet

Reporting Person: *

Phone Number/E-Mail:*

School Name:*

School District:*

Police Jurisdiction:

Type of Incident:

Report of Bullying

Yes

No

Weapons in School

Yes

No

Threats                                 

Yes

No

Fight                                                        

Yes

No

Other

Yes

No

Please describe in detail the incident and provide the names of those persons involved, the date of the incident, location of the incident, potential witnesses and any other useful information you may have:*

(LCSO 042012)