JGHS Bullying Report Form
"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:
*Places the targeted student in reasonable fear of harm to the targeted student's person or property
*Has a substantially detrimental effect on the targeted student's physical or mental health
*Has the effect of substantially interfering with the targeted student's academic performance or
*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
Bullying fosters a climate of fear and disrespect that can seriously impair the physical and psychological health of its victims and create conditions that negatively affect learning. Bullying includes unwanted, aggressive behavior that:
*Involves a real or perceived power imbalance
*Is repeated, or has the potential to be repeated, over time
*Controls or harms others

If you believe that you or another student is in immediate danger, contact the principal, Mr. Morton or Mr. Winchell immediately.

(Optional)
Your answer
Grade & School: *
Reporting Person (Upstander)
Role of Person Reporting Incident (Upstander): *
Have you reported this incident to a staff member? *
Staff Member Name(s) & Date(s) of Report:
Your answer
Student Victim #1: *
First & Last Name
Your answer
Grade & School: *
Student Victim #1
Student Victim #2:
First & Last Name
Your answer
Grade & School:
Student Victim #2
Student Victim #3:
First & Last Name
Your answer
Grade & School:
Student Victim #3
Alleged Perpetrator #1 (Bully): *
First & Last Name
Your answer
Grade & School: *
Alleged Perpetrator #1 (Bully)
Alleged Perpetrator #2 (Bully):
First & Last Name
Your answer
Grade & School:
Alleged Perpetrator #2 (Bully)
Alleged Perpetrator #3 (Bully):
First & Last Name
Your answer
Grade & School:
Alleged Perpetrator #3 (Bully)
Witness #1
First & Last Name
Your answer
Grade & School:
Witness #1
Witness #2
First & Last Name
Your answer
Grade & School:
Witness #2
Witness #3
First & Last Name
Your answer
Grade & School:
Witness #3
Date of Incident *
MM
/
DD
/
YYYY
Location(s) of Incident: *
School Locations Listed are at Urey
Required
Type(s) of Incident (Bullying): *
Required
Describe the incident(s) in detail.
Your answer
List any evidence that documents or supports this allegation. (notes, emails, texts, photos, etc)
Your answer
List any additional information that you would like to provide
Your answer
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