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Bullying Incident Report Form

Indiana’s Bullying Legislation: IC 20-33-8-0.2 “Bullying” Sec, 0.2 As used in this chapter, “bullying” means overt, repeated acts or gestures, including: (1) verbal or written communications transmitted; (2) physical acts committed; or (3) any other behaviors committed; by a student or group of students against another student with the intent to harass, ridicule, humiliate, intimidate, or harm the other student.

Which school does the complainant(s) attend?

Concord High School
Concord Junior High School
Concord Intermediate School
Concord East Side Elementary
Concord Ox Bow Elementary
Concord South Side Elementary
Concord West Side Elementary

Date of Incident

Time of Incident

Repeat activity?

Yes
No

Name of victim(s):

Name of bully:

Name(s) of witnesses/bystanders:

Type of bullying:

Physical bullying (pushing, shoving, hitting, threats, vandalism, theft, etc.)
Emotional bullying (name calling, insults, teasing; harassing phone calls, texts, DMs, etc.)
Social bullying (gossiping, teasing about appearance, exclusion, public humiliation, etc.)
Cyber-bullying (texting/messaging threats, defamatory web posts, derogatory emails, etc.)
Other (please explain)