Student Statement Form

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"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:
(1) places the targeted student in reasonable fear of harm to the targeted student's person or property;
(2) has a substantially detrimental effect on the targeted student's physical or mental health;
(3) has the effect of substantially interfering with the targeted student's academic performance; or
(4) 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.

Today's Date *

YYYY

What School is this happening at? *

Name of person completing this report

Who was the victim of the bullying? (Who was the student hurt by the words or actions of another person?) *

If the victim was you, have you been bullied or harassed by this person before? *

If your answer is yes, please state how many times you have been bullied or harassed by this person

If you have been bullied or harrassed by this person before, please indicate how many times you have reported it to school administration.

1 times

2 times or more

Never

Other

Clear selection

List the student or students who bullied another student by what they said or what they did. *

If this has happened before, when did the first event occur?

YYYY

What category of bullying does this incident fall under? *

Choose all that apply

PHYSICAL-involves hurter a person's body or possessions. It includes hitting/kicking/punching, spitting, tripping or pushing, taking or breaking someone's things, and making mean or rude hand gestures.

VERBAL- Involves saying mean things. It can include teasing, name-calling, inappropriate sexual comments, taunting, or threatening to cause harm.

SOCIAL/RELATIONAL-Involves hurting someone's reputation or relationships. Social bullying involves telling other children not be friends with someone, leaving someone out on purpose, spreading rumors about someone, or embarrassing someone in public.

ELECTRONIC OR WRITTEN COMMUNICATION-Involves cyber-bullying, collective or group note writing, any bullying undertaken through the use of electronic devices (computer, cell phones, etc.)

Required

Where did the incident happen? *

Choose all that apply

On school property

On a school bus

At a school sponsored event

On the way to/from school

In the hallway

In the cafeteria

Other:

Required

What period did this event occur?

If this happened between classes in the hallway, please list between what two periods it happened. (Example: Between 2nd and 3rd Period)

If this happened in a classroom, who was the teacher in the class that this happened?

Have you reported this incident to anyone? If yes, please list who you reported it to AND when you reported it.

Did you tell the teacher in the classroom that this happened about this incident? *

Yes

Does Not Apply

If the location was on school property please state the exact location.

Mark the box next to the statement that best describes what happened. *

Hitting, kicking, shoving, spitting, hair pulling, or throwing something

Getting another person to hit or harm a student

Teasing, name calling, criticizing or threatening, in person or by other means

Making rude/threatening gestures

Purposely excluding a student

Using intimidation to make someone do something they don't want to

Spreading harmful rumors or gossip

Other:

Required

Did a physical injury result from this incident? If yes, please describe what injury occurred. *

What did the alleged offenders say or do? *

Explain in detail please! Be sure to give the exact words the person used and/or exactly what actions the person took against another person.

Why do you think this incident happened? What do you think caused this to occur? *

Explain in detail please!

List the first and last names of any witnesses that were present when this incident happen. *

List any evidence of the bullying or harassment that supports your report of this incident. *

Please submit any tangible evidence to school administration by giving it to the school secretary. (i.e., letters, texts, photos, etc.)

STATEMENT OF UNDERSTANDING *

By submitting this document to NNSC you agree that all of the information on this form is accurate and true to the best of your knowledge.

I agree

I disagree

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