Anonymous Bullying Incident Report

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Indiana's Bullying Legislation:
IC 20-33-8-0.2 "Bullying" Sec, 0.2 As used in this chapter "bullying" means overt, repeated acts or gestures, including: (1) verbal or written communications transmitted; (2) physical acts committed; or (3) any other behaviors committed; by a student or group of students against another student with the intent to harass, ridicule, humiliate, intimidate, or harm the other student.

Bullying Incident Report Form
Please complete the bullying incident report. This report is anonymous. If you have an immediate concern, please contact the school administration.

Please check the type(s) of bullying you are reporting. *

Physical Bullying

Verbal Bullying

Social Bullying

Cyber Bullying

Required

Type the name of the student(s) that are bullying. *

Type the name of the student(s) being bullied. *

Please describe the bullying incident(s) and area(s) in which the bullying is occurring. *

When did this happen? Try to be as accurate as possible. *

YYYY

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This form was created inside of Medora Community School.