Form 3316 - Harassment, Intimidation Or Bullying (Hib) Incident Reporting Form
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2Harassment, Intimidation or Bullying (HIB)
Incident Reporting Form
RCW 28A.300.285 defines harassment, intimidation, or bullying as an intentional, electronic, written, verbal or
physical act that:
Physically harms a student or damages the student’s property; or
Has the effect of substantially interfering with a student’s education; or
Is so severe, persistent or pervasive that it creates an intimidating or threatening educational
environment; or
Has the effect of substantially disrupting the orderly operation of the school.
Reporting person (optional): ___________________________________________________________________
Targeted student: _________________________________________ School:___________________________
Your email address (optional): __________________________________________________________________
Your phone number (optional): ________________________________ Today’s date: ____________________
Name of school adult you’ve already contacted (if any): _____________________________________________
Name(s) of bullies (if known):
___________________________________________________________________________________________
On what dates did the incident(s) happen (if known):
___________________________________________________________________________________________
Where did the incident happen? Circle all that apply.
Classroom
Hallway
Restroom
Playground
Locker room
Lunchroom
Sport field
Parking lot
School bus
Internet
Cell phone
During a school activity (before or after school)
Off school property
On the way to/from school
Other (Please describe) _______________________________________________________
Please check the box that best describes what the bully 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 and 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
Spreading harmful rumors or gossip
Cyber bullying (bullying by calling, texting, emailing, web posting, etc.)
Other
If you select other, please describe: _____________________________________________________________
A copy of this report and supporting documentation must be sent to HIB Compliance Officer after investigation is complete.
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Form 3316_7/15_DLT
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