Bullying Report Form

Bullying Report Form

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. 

 

Name of Targeted Student: 

Today's Date: 

School: 

Name of Person Making Report: 

Relationship to Targeted Student: 

Contact information of person making report: 

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)   

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

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? *

When did this bullying take place? 

How often does it happen? 

Who did this to your or to the targeted student? 

What was happening before the bullying started? 

State what the bully (perpetrator) said/did: 

State what you or targeted student said/did: 

Who else was around who saw or hears this happen? 

What made you decide that you need to report this? 

Was there physical injury? 

Was the injury report at school? 

To whom? *

Additional comments: 

 



Security Measure