H.I.B. Incident Reporting Form


Use the form below to report any type of harassment, intimidation, or bullying incident to a district administrator.

For more information on H.I.B. matters, please download the attached brochure.



Items denoted with a red asterisk * are required.
Today's date
 
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 * School building
 
Reporting person
 
 * Your relation to the district
 
Your email address
 
Your phone number
 
Name of school adult you've already contacted (if any)
 
 * Targeted student
 
Name(s) of aggressors (if known)
 
Is the aggressor a district employee?
 
On what days did the incident happen (if known)
 
Where did the incident happen (e.g. Classroom, Playground, Internet, School Bus)? Please list all areas.
 
Please describe what the aggressor did. (e.g. Hitting, teasing, threatening, exploiting, etc.)
 
Why do you think the harassment, intimidation, or bullying occurred?
 
Please name any witnesses. (Leave blank if no witnesses)
 
Please describe any physical injury that occurred as a result of this incident. (Leave blank if no physical injuries occurred.)
 
If the target was absent from school as a result of the incident, please describe. (Leave blank if not absent.)
 
Is there any additional information?
 
 
 
Warning: It is a violation of district operational procedure to knowingly report false allegations of harassment, intimidation, and bullying. Students or employees will not be disciplined for making a report in good faith. However, persons found to knowingly report or corroborate false allegations will be subject to appropriate discipline.