Jac-Cen-Del Alleged Bullying Reporting Form
NOTE: This Bullying reporting form is only reviewed during normal school hours.
If this is an emergency call 911
Indiana Criminal Code (IC 20-33-8.0.2) defines bullying: Bullying means overt, repeated acts or gestures, including :
1) Verbal or written communications transmitted;
2)Physical acts committed:
3)any other behaviors committed, by a student or group of students against another student with the intent to:
1) harass / and-or
2) ridicule /and-or
3) humiliate /and-or
4) intimidate /and-or
5) harm the other student

Date of Alleged Bullying *
MM
/
DD
/
YYYY
*
Time
:
Location *
Your answer
Person Completing Form (Not required)
Your answer
Student(s) Initiating Bullying *
Your answer
Student(s) Affected *
Your answer
Student Witnesses *
Your answer
Type of Bullying Alleged (Check All That Apply) *
Required
Describe the Incident(s): *
Your answer
Physical Evidence:
i.e. Text Msg/Voice Msg/Notes, etc.
Your answer
Submit
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