Bullying Report and Incident Form
Bullying as defined by IC 20-33-8-0.2 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 targeted student and create for the targeted student an objectively hostile student environment.
Please complete this anonymous form and submit it when finished. If you have an immediate concern, please contact a school administrator or teacher.
Date of incident
This incident involves students in:
junior high/ high school
both elementary school and junior high/ high school
Name of target of the bullying incident (student being bullied):
Name of alleged offender (person doing the bullying):
Type of bullying (check all that apply)
Written or electronic
Brief explanation of incident:
Where did the incident happen?
Did a physical injury result from this incident?
Yes, but it did not require medical attention
Yes, and it did require medical attention
If medical attention was required, please describe:
Any other information you would like to provide to help in our investigation:
The school district is not authorized to disclose to a target, private educational or personnel data regarding an alleged perpetrator who is a student or employee of the school district. School officials will notify the parent(s) or guardian(s) of all students involved in a bullying incident and the remedial action taken, to the extent permitted by law, based on a confirmed report.
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This form was created inside of Springs Valley Community Schools.