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
MM
/
DD
/
YYYY
This incident involves students in:
Name of target of the bullying incident (student being bullied):
Your answer
Name of alleged offender (person doing the bullying):
Your answer
Type of bullying (check all that apply)
Required
Brief explanation of incident:
Your answer
Where did the incident happen?
Your answer
Did a physical injury result from this incident?
If medical attention was required, please describe:
Your answer
Any other information you would like to provide to help in our investigation:
Your answer
Note:
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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