2021-2022 London HIB Referral Form
The Board of Education is committed to providing a safe, positive, productive, and nurturing educational environment for all of its students.  The Board encourages the promotion of positive interpersonal relations between members of the school community.  

Harassment, intimidation, or bullying towards a student, whether by other students, staff, or third parties is strictly prohibited and will not be tolerated.  This prohibition includes aggressive behavior, physical, verbal, and psychological abuse, and violence within a dating relationship.  The Board will not tolerate any gestures, comments, threats, or actions which cause or threaten to cause bodily harm or personal degradation.  This policy applies to all activities in the District, including activities on school property, on a school bus, or while en route to or from school, and those occurring off school property if the student or employee is at any school-sponsored, school-approved or school related activity or function, such as field trips or athletic events where students are under the school's control, in a school vehicle, or where an employee is engaged in school business.  

This policy has been developed in consultation with parents, District employees, volunteers, students, and community members as prescribed in R.C. 3313.666 and the State Board of Education's Model Policy.  Parents and guardians can refer to London City Schools Board Policy number 5571.01 for more information.  

Harassment, intimidation, or bullying means:

A. any intentional written, verbal, electronic, or physical act that a student or group of students exhibits toward another particular student(s) more than once and the behavior both causes mental or physical harm to the other student(s) and is sufficiently severe, persistent, or pervasive that it creates an intimidating, threatening, or abusive educational environment for the other student(s); or

B. violence within a dating relationship.
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:

District Anti-(HIB) Harassment, Intimidation, and Bullying Coordinator: Dr. Lou Kramer, London City Schools Superintendent/740-845-3282; lou.kramer@london.k12.oh.us

London High School Building Anti-HIB Coordinator: Mr. Kyle Cutler/740-845-3284; kyle.cutler@london.k12.oh.us

London Middle School Building Anti-HIB Coordinator: Mr. James Stutzman/740-845-1279; james.stutzman@london.k12.oh.us

London Elementary School Building Anti-HIB Coordinator: Mr. Roy Ohr/740-845-3272; roy.ohr@london.k12.oh.us


Sign in to Google to save your progress. Learn more
Email *
*
MM
/
DD
/
YYYY
Phone Number *
I am a ... *
Required
Referral Information *
Please provide the name(s) of all persons (including yourself, if applicable) who were the target of harassment, intimidation, bullying, or retaliation.
Referral Information *
Please provide the name(s) and/or description of all individuals (students, school employees, school visitors, or others) who engaged or participated in the alleged harassment, intimidation, bullying, or retaliation.  (If known)
Description of Incident *
Details about the incident(s); Names of witnesses, place of incident, and time of incident.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of London City Schools. Report Abuse