Bullying Report Form
What is Bullying?
"Bullying" (per IC 20-33-8-.2) means overt, unwanted, repeated acts or gestures, including verbal or written communications or images transmitted in any manner (including digitally or electronically), physical acts committed, aggression, or any other behaviors, that are committed by a student or group of students against another student with the intent to harass, ridicule, humiliate, intimidate, or harm the other targeted student and create for the targeted student an objectively hostile school environment that:
(1) places the targeted student in reasonable fear of harm to the targeted student's person or property;
(2) has a substantially detrimental effect on the targeted student's physical or mental health;
(3) has the effect of substantially interfering with the targeted student's academic performance; or
(4) has the effect of substantially interfering with the targeted student's ability to participate in or benefit from the services, activities, and privileges provided by the school.
Name of person being bullied:
Date bullying occurred:
Name of bully:
Your Name (optional):
I am a:
Person being bullied
Type of bullying (select all that apply):
Physical - hitting, kicking, other physical aggression
Verbal - Teasing, name-calling, put-downs, behavior that would hurt others' feelings or make them feel badly
Social/Relational - starting rumors, telling others not to be friends with someone/actions that would cause someone to be without friends
Electronic or Written Communication - Using an electronic medium to engage in any previously mentioned "bullying"
Description of events (please be specific-location/date/time)
Did you witness the bullying?
List other students/staff who witnessed the bullying:
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This form was created inside of Greensburg Community Schools.