Harassment, Intimidation & Bullying (Hib) Reporting Form printable pdf download

School #

Written Report #

Garfield Public School District: Harassment, Intimidation & Bullying (HIB) Reporting Form

Directions: Harassment, Intimidation & Bullying are serious offenses and will not be tolerated. This form is to report an alleged

incident that occurred on school property, at a school sponsored event or activity, off of school property, or on a school bus. Please

complete this form and return to the School Principal or Anti-Bully Specialist, even after you have verbally reported the

incident. You may report anonymously. Please contact your school’s office for additional information or assistance.

*(a separate investigation report form is required for EACH targeted pupil)*

Name\Contact of Reporter:

Date of Verbal Report:

Date of Written Report:

Check One:

Student

Staff Member

Signature of Reporter:

Parent\Guardian

Volunteer

Anonymous

Name of Targeted Pupil:

Date of Incident:

Location of Incident:

Time of

Incident:

Name of Student(s)/Person(s) Accused of HIB Behavior:

Mark ALL boxes below in which the actual or perceived characteristic was or may have been a motivational factor

in the alleged HIB incident:

Race:

Color:

Religion:

Ancestry:

National Origin:

Gender:

Sexual Orientation:

Gender Identity/Expression:

Mental or Physical or Sensory Disability:

Other actual or perceived characteristic: (Please list)

Type of Incident: (Check all that apply)

Gesture

Written

Verbal

Physical

Electronic

Communication

Witnesses of Incident:

Check next to ALL the statement(s) that best describes what happened.

Any bullying, harassment or intimidation that involves

Making rude and/or threatening gestures

physical aggression

Excluding or rejecting the student

Getting another person to hit or harm the student

Intimidating (bullying), extorting or exploiting

Teasing, name-calling, making critical remarks or

Spreading harmful rumors or gossip

threatening, in person or by other means

Electronic communication (specify)

Demeaning & making the targeted pupil of jokes

Other (specify)

Describe nature of alleged harassment, intimidation or bullying. Include any gesture, relevant verbal, written or

physical act(s), or any electronic communication.

What harm do you believe was or may have been caused by the alleged incident? Check all that apply.

Substantial disruption or interference with orderly operation of

Insulted or demeaned a student or a group of

school rights of others:

students:

Target was in fear of physical or emotional harm or damage to

Accused knew action would physically or emotionally

cause harm or damage target’s property:

personal property:

Interferes with student’s education:

Creates a hostile educational environment by severely or pervasively causing

physical or emotional harm to the student:

*Students/Parents ONLY may choose to submit this report anonymously. Please note, in accordance with the Anti-Bullying Bill of

Rights Act, no formal disciplinary action is permitted on the basis of anonymous reporting alone.*

Name/Signature of Person Receiving Report

Title

Date Received

Updated: July 2015

CONFIDENTIAL

Harassment, Intimidation & Bullying (Hib) Reporting Form

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