Elementary Bully Report Form

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San Pierre
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Elementary Bully Report Form

10/17/2019

Elementary Bully Reporting Form

This form may be used by anyone who experiences or witnesses bullying of a North Judson-San Pierre Elementary School student. Fill the form out fully and hit the SUBMIT button to turn it into the elementary school principal.

Date(*)

Please select a date.

Your Name

Invalid Input

Did you witness the bullying?(*)

Yes No Please specify yes or no.

I am a
(*)

Student
Staff Member
Parent/Guardian
Person being bullied
Community Member
Friend Please choose one or more of the following.

Name of person being bullied(*)

Please enter the name of the person being bullied.

Enter name of bully and their grade/school (if known). If there was more than one bully, add their names here too.

Invalid Input

Where did this take place?

Classroom (see below)
Lunchroom
Restroom
In the hallway
At recess time
Online/email/text
Bus stop
On the bus
Going to/from school Invalid Input

If you selected classroom, please identify which room.

Invalid Input

Type of Bullying
(Select all that apply)(*)

Physical Aggression
Excluding or rejecting
Social Media
Making the Victim of Jokes
Related to perceived sexual orientation
Threatening
Spreading Rumors
Text Messaging
Related to Disability
Teasing/Name Calling
Inappropriate Gestures
Written Communication
Related to Race Please select the type of bullying.

Description of events
(Please be specific - use exact wording, names, dates, location and time, etc.):(*)

Please describe the event.

Why did the bullying happen?(*)

Please describe the event.

What has been done to help stop the bullying?(*)

Told the person to stop
Moved away from the person
Ignored the situation or did nothing
Tried to make a joke of it; laughed it off
Tried to talk to the person
Told an Adult Please choose one or more of the following.

Please list other students/staff who may have witnessed the bullying incident described above:

Invalid Input

Please use this space to tell us anything else about the bullying.

Invalid Input

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.

Human Verification

Invalid Input

- Central Office
  North Judson-San Pierre School Corporation
  Dr. Annette Zupin, Superintendent
  801 Campbell Dr.
  North Judson, IN 46366
  
  Voice: 574-896-2155
  
  Jr./Sr. High School
  North Judson-San Pierre Jr./Sr. High School
  1 Bluejay Dr.
  North Judson, IN 46366
  
  Voice: 574-896-2158
  Fax: 574-896-2060
  
  James Polite, Principal
  
  Elementary
  North Judson-San Pierre Elementary School
  809 West Talmer Ave.
  North Judson, IN 46366
  
  Voice: 574-896-2128
  Fax: 574-896-2129
  
  Julie Berndt, Principal
- Purpose
  Preparing Today's Youth for Tomorrow's Opportunities
  
  Vision
  Building a foundation and fostering opportunities for growth, so students can graduate, college and career ready.
  
  Direction
  Teaching students to be responsible, respectful, caring achievers through the Bluejay Way.
  
  Connect With Us
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  Bullying Policy
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Copyright © North Judson-San Pierre Schools

It is the policy of the North Judson-San Pierre School Corporation not to discriminate on the basis of race, color, religion, sex, national origin, age, or disability in its educational programs or employment policies as required by the Indiana Civil Rights Act, Titles VI and VII of the Civil Rights Act of 1964, the Equal Pay Act of 1973, Title II, Title IX and Section 504 of the Rehabilitation Act of 1973. ” Questions and concerns should be directed to the Title IX, Title II, and Section 504 Coordinator as follows: Dr. Annette Zupin, Superintendent of Schools c/o North Judson-San Pierre Schools 801 Campbell Dr., North Juson, IN 46366 Phone: (574) 896-2155

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