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(HIB) Harassment, Intimidation, and Bullying Form
MSD Decatur prohibits discrimination, harassment, intimidation, and bullying in all forms, including on the basis of a student's actual or perceived race, color, national origin, ethnicity, religion, sex, gender (including nonconformity with gender stereotypes, gender identity, and gender expression), sexual orientation, and disability, or on the basis of a person's association with a person or group with one or more of these actual or perceived characteristics. If you or someone you know has experienced harassment, intimidation, or bullying at school for any reason, you may make a referral to have the incident (s) investigated by the District. Any student, parent/guardian, or school employee may complete this form and return it to any school employee. Alternatively, you may make a verbal or other written complaint to any school employee. Any school employee who receives a completed referral form or any other written or verbal complaint will immediately report the complaint to the Anti-HIB Building Coordinator to handle the harassment complaints. The designated school official will investigate and resolve the complaint under the District's policies and regulations, and consistent with all applicable federal and state laws. Contact information for the Anti-HIB District Coordinator and the Anti-HIB Building officials can be found in the Student Handbook.
The District will respect the privacy of students to the extent permitted by District policy and state and federal law. Retaliation against any individual who makes a complaint or who participates or assists in an investigation of harassment, intimidation, or bullying is strictly prohibited. Please provide as much information as possible. All requested information is optional.
If you have any questions before submitting your complaint, please contact:
Liberty Preschool
317-486-4203
Susan Bryant, Preschool Director
sbryant@decaturproud.org
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Date of Complaint
MM
/
DD
/
YYYY
Name of Person Making the Complaint
You may choose to be anonymous
Your answer
Phone Number
Your answer
Email Address
Your answer
I am
Parent
Student
Employee
Other
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Name of person being bullied or harassed
Your answer
Complaint Information
Please provide the name(s) of all persons (including yourself, if applicable) who were the target of harassment, intimidation, or bullying.
Your answer
Complaint Information
Description of Complaint/Incident (e.g. date, time, and place of harassment; details about the incidents (s); names of witnesses).
Your answer
I have been bullied because of
Sex/Gender
Race
Disability
National Origin
Religion
Other:
Type of Bullying (Check all that apply)
Physical - Hitting, kicking, or 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 to engage in any previously mentioned "bullying"
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