Form 3316 - Harassment, Intimidation Or Bullying (Hib) Incident Reporting Form Page 2
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2Harassment, Intimidation or Bullying (HIB)
Incident Reporting Form
Why do you think the harassment, intimidation or bullying occurred?
___________________________________________________________________________________________
Were there any witnesses? Yes
No
If yes, please provide their names:
___________________________________________________________________________________________
___________________________________________________________________________________________
Did a physical injury result from this incident? If yes, please describe.
___________________________________________________________________________________________
Was the target absent from school as a result of the incident? Yes
No
If yes, please describe
___________________________________________________________________________________________
Is there any additional information?
___________________________________________________________________________________________
___________________________________________________________________________________________
Please return this form to your school’s front office for the principal. Thank you for reporting.
----------------------------------------------------------------For Office Use----------------------------------------------------------------
Received by: _______________________________________________________________________________
Date received: ___________________________________
Action taken: ______________________________________________________________________________
Parent/guardian contacted: ___________________________________________________________________
Circle one:
Resolved
Unresolved
Referred to: _____________________________________
A copy of this report and supporting documentation must be sent to HIB Compliance Officer after investigation is complete.
Page 2 of 2
Form 3316_7/15_DLT
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Parent category: Business