Harassment, Intimidation, or Bullying (HIB) Incident Reporting Form

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1. To be considered HIB, an incident must meet the criteria as defined in School Board Policy 3207 and Procedure 3207.

2. All reports should be addressed appropriately and in a timely manner, however, please note that no disciplinary action will be taken against an alleged perpetrator based solely on anonymous reporting.

3. Reports should be submitted to the school as a first step for investigation.

Today's Date *

YYYY

Reporting Person First Name *

Reporting Person Last Name *

Phone Number

Email Address

Interpreter Needed?

Yes

Clear selection

Targeted Student Name *

Alleged Aggressor Name *

List dates and times when incidents occurred. *

Where did the incident occur? (Select all that apply) *

Classroom

Hallway

Lunchroom/Flex Space

Park

Gym

Parking Lot

Restroom

School Van

Public Transportation

Social Media

Electronic Device

Off school property

on the way to/from school

During a school activity

Other

Required

Describe the incident, providing specific details. *

How is the targeted student feeling/affected by the incident and why?

Were there any witnesses? *

Yes

Did a physical injury result from the incident(s)? *

Yes

Was the targeted student absent from school as a result of the incident(s)? *

Yes

Not Sure

Name of school adult you have contacted about this issue (if any) and what was the response?

What are your desired next steps, or how would you like the school to resolve this concern? *

Submit

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