Enumclaw Middle School H.I.B. (Discrimination, Harassment, Intimidation, and/or Bullying) Reporting Form

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In order to ensure respect and prevent harm, it is a violation of District Policy 3207 for a student or staff member to be harassed, intimidated, or bullied by others in the school community, at school-sponsored events, or when such actions create a substantial disruption to the educational process.

Student(s) nor staff will not be harassed, intimidated, or bullied because of their race, color, religion, ancestry, national origin, gender, sexual orientation, including gender expression or identity, mental or physical disability, or other distinguishing characteristics.

Any school staff or student who observes, overhears, or otherwise witnesses harassment, intimidation, or bullying or to whom such actions have been reported must take prompt and appropriate action to stop the behavior and to prevent its recurrence. This completed form will be submitted to the appropriate school administrator or discipline officer, the incident shall be investigated, and the Civil Rights Compliance Coordinator, Stephanie Berryhill, shall receive a copy of the document generated by the investigation.

Stephanie Berryhill
Title IX/Chapter 28A.640 RCW Officer
Civil Rights Compliance Coordinator
2929 McDougall Ave.
Enumclaw, WA 98022
360.802.7113

Reports of harassment, intimidation, or bullying may be filed anonymously, but please be aware that no action may be taken against an alleged aggressor based solely on an anonymous report.

The names of complainants, accusers, and witnesses will be redacted from this and all other investigative records prior to their disclosure if the district receives a public record request regarding this matter unless the individual has consented to disclosure of their name.

Policy 3207
https://www.enumclaw.wednet.edu/our-district/school-board/district-policies/district-policies-3000-series

Policy 3207P
https://www.enumclaw.wednet.edu/our-district/school-board/district-policies/district-policies-3000-series

Name:

Confidential:

Although I have given my name, I want my report to remain confidential. I understand that no disciplinary action may be taken against an alleged aggressor based solely on a confidential report.

Your email address:

Your phone number:

Name of school adult already contacted (if any):

Targeted student or staff member:

Alleged aggressor (if known):

On what date(s) did the incident(s) happen:

YYYY

Where did the incident happen? Please select all that apply.

Classroom

Hallway

Restroom

Playground

Locker Room

Lunchroom

Sport Field

Parking Lot

School Bus

Internet/Social Media

Cell Phone

During a School Activity

Off School Property

On the way to/from school

Other:

Please provide any additional information regarding the location of the incident (ex. which classroom, period, etc.)

Please check the box that best describes what the aggressor did. Please choose all that apply *

Hitting, kicking, shoving, spitting, hair pulling or throwing something at the student

Getting another person to hit or harm the student

Teasing, name calling, making critical remarks or threatening in person, by phone, by e-mail, etc.

Putting the student down or making the student a target of jokes

Making rude and/or threatening gestures

Excluding or rejecting the student

Making the student fearful, demanding money, or exploiting the student

Spreading harmful rumors or gossip

Cyber bullying (bullying by calling, texting, emailing, web posting, etc.)

Other:

Required

Please describe the incident

Were there any witnesses?

Yes

Clear selection

If yes, please provide their names:

Did a physical injury result from this incident?

Yes

Clear selection

If yes, please describe.

Is there any additional information you wish to provide?

Thank you for reporting!

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