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Choctaw County Schools
107 Tom Orr Drive, Butler, AL 36904
P: 205-459-3031
F: 205-459-3037
Home
Employee Portal
About
Schools
Choctaw County Elementary
Southern Choctaw Elementary
Choctaw County High
Southern Choctaw High
Departments
Superintendent
Accountability and Assessments
Business Support Services
Career and Technical Education
Child Nutrition
Community Education
Curriculum and Instruction
Gifted and Speech Services
Federal Programs
Health
Professional Development
Human Resources
School Social Worker
Special Education
Southern Choctaw High School Bullying Report Form
Today's Date:
Name of Victim:
Age of Victim:
Name of Offender:
Age of Offender: (if known)
Is he/she a student?
Yes
No
School of Offender: (if known)
Choctaw County Elementary
Choctaw County High
Southern Choctaw Elementary
Southern Choctaw High
Name of Any Additional Alleged Offender:
Date of Incident:
Additional Date Incident Happened:
Where did Incident Happen?
On school property
On a school bus
At a school-sponsored activity or event off school property
Place check next to the statement(s) that best describes what happened (Choose all that apply):
Hitting, kicking, shoving, spitting, hair pulling, or throwing something
Coercing another person to hit or harm the student
Repeated teasing, name-calling, making critical remarks, or threatening, in person or by other means
Making rude and/or threatening gestures
Intimidating, bullying, extorting, or exploiting
Spreading harmful rumors or gossip
Electronic Communications (specify below)
Other (specify below)
Did a physical injury result from this incident?
Yes
No
If there was a physical injury, do doctors think there will be permanent effects?
Yes
No
Was the student victim absent from school as a result of this incident?
Yes
No
If yes, how many days was the student victim absent from school as a result of the incident?
Did a psychological injury result from this incident?
Yes
No
What did the alleged offender(s) say or do?
Why did the bullying, harassment or intimidation occur?
Is there any additional information you would like to provide?
Thank you for contacting us.
We will get back to you as soon as possible.
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107 Tom Orr Drive
Butler, AL 36904
P: 205-459-3031 - F: 205-459-3037
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