HIB Incident Form: Local Educational Agency Personnel (LEAs)

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All allegations of HIB must be reported in writing and submitted to the principal within two school days from when a school employee or contracted service provider, witnesses or receives reliable information, that a student has been subject to HIB.

The use of this form for reporting incidences of HIB is required.
This form shall be completed even if a preliminary determination is made under the LEA’s policy that the reported incident or complaint is a report outside the scope of the definition of HIB.
Required investigative procedures shall continue after the submission of this form to the school principal.
The completed form must be kept on file in the school.
The principal must promptly submit a copy of this form to the superintendent.

Directions

Complete the form below to provide detailed information of the alleged HIB incident. If fields are not applicable or if the completing party is uncertain of the response, those fields may be left blank.

Form

School Information

School District:

School:

Individual Completing Form

If you prefer to remain anonymous, leave this section blank.

Name of individual completing this form:

Role of individual completing the form

(e.g., teacher, lunchroom monitor, school bus driver, etc.):

Phone number:

Email address:

Incident Information

If you don’t know the answer please write in N/A where applicable.

Incident date

YYYY

Approximate time of the incident:

Time

Describe the incident with as much detail as possible. (What was the incident? Who was involved in the incident? How you were made aware of the incident? What happened at the time of the incident? How did the incident occur?)

Specific incident location(s) (e.g., on the morning school bus, in the science wing hallway, online via social media, etc.)

Alleged Offender(s)

If you don’t know the answer please write in N/A where applicable.

Name(s) of alleged offender(s):

Based on your knowledge, select all that apply about the alleged offender(s):

Alleged offender(s) attends the above-named school.

Alleged offender(s) attends another school.

Alleged offender(s) works for the school/school district.

Alleged offender(s) does not work for the school/school district.

Alleged Victim(s)

If you don’t know the answer please write in N/A where applicable.

Name(s) of alleged victim(s):

Based on your knowledge, select all that apply about the alleged victim(s):

Victim(s) attends the above-named school.

Victim(s) attends another school.

Witness

Complete this section with the names of any potential witnesses. If you don’t know the answer please write in N/A where applicable.

Student Names:

Staff Names:

Parent Names:

Other Names (specify title or position for each):

Alleged Bullying Behavior(s)

If you don’t know the answer please write in N/A where applicable.

Select the statement(s) that best describes the alleged bullying behavior (Check all that apply).

Verbal (e.g., teasing, name calling, derogatory comments, etc.)

Emotional (e.g., group exclusion, spreading rumors, taking belongings, etc.)

Physical (e.g., hitting, pushing, inappropriate touching, etc.)

Electronic (e.g., attacking through social media, cyberbullying, offensive messaging, etc.)

Submit

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