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04/20/2018
Bully Incident Reporting 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.
Bullying Incident Report Form
Please complete the bullying incident report. This report is anonymous. If you have an immediate concern, please contact the school's administration.
(*) Required
Please select all that apply
(*)
Physical
- Hitting/kicking/other physical aggression.
Verbal
- Teasing, name calling, put-downs, or other behavior that would hurt others' feelings or make them feel bad.
Emotional/Exclusion
- Starting rumors, telling others not to be friends with someone or other actions that would cause someone to be without friends.
Cyber-bullying
- Using an electronic medium (including but not limited to: texts, e-mails, phone messages, facebook, etc.) to engage in any previously mentioned "bullying."
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Type the name of the student(s) that are bullying and the school they attend.
(*)
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Where did the bullying take place?
Jr. Sr. High School
Elementary School
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Name of the student being bullied
(*)
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Which school does this student attend?
Jr. Sr. High School
Elementary School
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Description of Events (Please be specific - use exact wording, names, place, time, etc..)
(*)
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When did this happen?
(*)
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The administrators will investigate the report and take appropriate actions to deal with the situation. Since much of what we do needs to remain confidential, you may not know of the steps we take to stop the bullying. If the bullying does not stop, we need to take additional steps. Please let us know if the bullying continues.
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Corporation Office
Pioneer Regional School Corporation
413 S. Chicago St.
Royal Center, IN 46978
Mr. Charles Grable, Supt.
Phone: 574-643-2605
Fax: 574-643-9977
Jr./Sr. High School
Pioneer Jr./Sr. High School
417 S. Chicago St.
Royal Center, IN 46978
Mr. Jeremy Tucker, Principal
Phone: 574-643-3145
Fax: 574-643-2020
Elementary School
Pioneer Elementary School
109 E. Black Lane
Royal Center, IN 46978
Dr. Beth Dean, Principal
Phone: 574-643-2255
Fax: 574-643-4029
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