JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Washington State Harassment, Intimidation or Bullying (HIB)
Incident Reporting Form
Sign in to Google
to save your progress.
Learn more
Reporting Person (optional)
Your answer
Targeted student
Your answer
Your email address (optional)
Your answer
Your phone number (optional)
Your answer
Today's date
MM
/
DD
/
YYYY
Name of school adult you've already contacted (if any)
Your answer
Name(s) of aggressor(s) (if known)
Your answer
On what date did the incident(s) happen (if known)
MM
/
DD
/
YYYY
Where did the incident happen? Check all that apply.
Classroom
Hallway
Restroom
Playground
Locker room
Lunchroom
Sport field
Gym
Parking lot
School bus
Online/internet
Cell phone
During a school activity
Off school property
On the way to/from school
Other
If other, please explain.
Your answer
Please check the box that best describes what the bully did. Please check all that apply.
Blocked movement
Damage to my property
Derogatory comments
Disrespectful comments
Electronic/Cyberbullying
Excluding me from activities
Hazing (Club, team, class, other)
Gender slurs
Gestures
Gossip
Intimidation directed at me
Name calling
Offensive writing or graffiti
Physical harm or threats of harm
Pranks
Put downs
Racial slur(s)
Repeated behavior
Sexual stories/jokes/pictures
Sexual orientation slurs
Slurs, rumors, jokes
Spreading rumors
Threats (to me, friends, school)
Touching/grabbing
Other
If other, please explain.
Your answer
Why do you think this occurred?
Your answer
Were there any witnesses?
Yes
No
Clear selection
If yes, please provide their names.
Your answer
Did a physical injury result from this incident?
Yes
No
Clear selection
If yes, please describe.
Your answer
Was the targeted student absent from school as a result of the incident?
Yes
No
Clear selection
If yes, please describe.
Your answer
Are there any notes, pictures, texts, screen shots or other evidence of the event(s) you are reporting?
Yes
No
Clear selection
If yes, please describe.
Your answer
is there any additional information you can add?
Yes
No
Clear selection
If yes, please describe.
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Bickleton School District.
Report Abuse
Forms
