RCSC 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 at your building immediately.
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Reporter's First Name
Reporter's Last Name
Reporter's Email Address
To receive a copy of this report, this must be completed.
Reporter Attends Which School *
Reporting Person (Upstander)
Role of Person Reporting Incident (Upstander) *
Have you reported this incident to a staff member? *
Staff Member Name(s) & Date of Report
Student Victim #1: *
First & Last Name
Grade & School *
Student Victim #1
Student Victim #2:
First & Last Name
Grade & School
Student Victim #2
Clear selection
Student Victim #3:
First & Last Name
Grade & School
Student Victim #3
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Alleged Perpetrator #1 (Bully) *
First & Last Name
Grade & School
Alleged Perpetrator #1 (Bully)
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Alleged Perpetrator #2 (Bully)
First & Last Name
Grade & School
Alleged Perpetrator #2 (Bully)
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Alleged Perpetrator #3 (Bully)
First & Last Name
Grade & School
Alleged Perpetrator #3 (Bully)
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Witness #1
First & Last Name
Grade & School
Witness #1
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Witness #2
First & Last Name
Grade & School
Witness #2
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Witness #3
First & Last Name
Grade & School
Witness #3
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Date of Incident *
MM
/
DD
/
YYYY
Location of Incident *
Required
Type(s) of Incident (Bullying) *
Required
Describe the Incident(s) in Detail
List any evidence that documents or supports this allegation. (notes, emails, texts, photos, etc)
List any additional information that you would like to provide
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