HIB Reporting Form for Parents

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Harassment and intimidation (bullying) are serious and will not be tolerated. This is a form to report alleged harassment and intimidation (bullying) that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; or on the way to and/or from school*, in the current school year. If you are a student victim, the parent/guardian of a student victim, or a close adult relative of a student victim, or a school staff member and wish to report an incident of alleged harassment or intimidation (bullying), complete this form and return it to the Principal at the student victim’s school. Contact the school for additional information or assistance at any time. Harassment and intimidation (bullying) means conduct, including verbal conduct, that creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities, or performance, or with a student’s physical or psychological well-being, and is motivated by an actual or a perceived personal characteristic such as race, national origin, marital status, sex, sexual orientation, gender identity, religion or disability, or is threatening or seriously intimidating.

Select Incident Reporting Date *

YYYY

Enter School Year Below *

School Name *

Name of Person Reporting Incident *

Telephone Number *

E-mail: *

Select the appropriate option in the dropdown menu below to describe the person reporting incident. *

Name of student victim *

Name(s) of alleged offender(s) (If known): Include Age; School; Is he/she a student? (If known) *

On what date(S) did the incident happen? *

Where did the incident happen (choose all that apply)? *

On school property

On a school bus

At a school-sponsored activity or event off school property

On the way to/from school*

Required

Select a statement(s) that best describes what happened* (choose all that apply): *

Hitting, kicking, shoving, spitting, hair pulling, or throwing something

Getting another person to hit or harm the student

Teasing, name-calling, making critical remarks, or threatening, in person or by other means

Demeaning and making the victim of jokes

Making rude and/or threatening gestures

Excluding or rejecting the student

Intimidating (bullying), extorting, or exploiting

Spreading harmful rumors or gossip

Other

Required

If "other was selected in the previous question, please specify. *

What did the alleged offender(s) say or do? *

Why did the harassment or intimidation (bullying) occur? *

Did a physical injury result from this incident? *

Yes, but it did not require medical attention

Yes, and it required medical attention

If there was a physical injury, do you think there will be permanent effects *

Yes

Was the student victim absent from school as a result of the incident? *

Yes

If yes was answered for the previous question, how many days was the student victim absent from school as a result of the incident? *

Did a psychological injury result from this incident? *

Yes, but psychological services have not been sought

Yes, and psychological services have been sought

Is there any additional information you would like to provide? *

Submit

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This form was created inside of Orange Public Schools. Report Abuse

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