Student Statement 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:
(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 *
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What School is this happening at? *
Name of person completing this report
Your answer
Who was the victim of the bullying? (Who was the student hurt by the words or actions of another person?) *
Your answer
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
Your answer
If you have been bullied or harrassed by this person before, please indicate how many times you have reported it to school administration.
List the student or students who bullied another student by what they said or what they did. *
Your answer
If this has happened before, when did the first event occur?
MM
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YYYY
What category of bullying does this incident fall under? *
Choose all that apply
Required
Where did the incident happen? *
Choose all that apply
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)
Your answer
If this happened in a classroom, who was the teacher in the class that this happened?
Your answer
Have you reported this incident to anyone? If yes, please list who you reported it to AND when you reported it.
Your answer
Did you tell the teacher in the classroom that this happened about this incident? *
If the location was on school property please state the exact location.
Your answer
Mark the box next to the statement that best describes what happened. *
Required
Did a physical injury result from this incident? If yes, please describe what injury occurred. *
Your answer
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.
Your answer
Why do you think this incident happened? What do you think caused this to occur? *
Explain in detail please!
Your answer
List the first and last names of any witnesses that were present when this incident happen. *
Your answer
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.)
Your answer
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.
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