Bullying Report

Bullying Report

Bullying as defined by IC 20-33-8-0.2 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 targeted student and create for the targeted student an objectively hostile student 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 privilege provided by the school.


Name of Targeted Student: 

Today's Date: 


Name of Person Making Report: 
(Reports may be anonymous or by self, teacher/staff, parent/guardian, volunteer, etc.)

Relationship to Targeted Student: 

Contact information of person making report: 
(Phone or email address)

Name of student prompting this report: 

1. What type of bullying took place? You can check more than one:

 Physical (hit, kicked, pushed, slapped, spat on, had property taken or destroyed)    

 Verbal (teased, mean things said, called names, threatened with harm)

 Social/Relational (excluded, ignored, rumors spread, others encouraged not to like targeted person)   

 Communication: Written/Electronic (others used computer, email or phone text used to threaten or make target look bad)

2. Is this the first time you have reported bullying?   Yes      No

If not the first time, how many times has it been reported: 

To whom? *

3. When did this bullying take place? 

Be specific: How often does it happen? 

4. State what the bully (perpetrator) said/did: 

5. State what you or targeted student said/did: 

6. How has this impacted you or the targeted student? 

7. Who else was around who saw or hears this happen? 

8. What made you decide that you need to report this? 

9. Was there physical injury?  Yes    No

Was the injury report at school?  Yes    No

To whom? *

Additional comments: 


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