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Hib Incident Report Form

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HIB Incident Report Form

WAYNE PUBLIC SCHOOLS

(available at )

PLEASE SUBMIT THIS FORM TO THE BUILDING PRINCIPAL

Name of Alleged Target(s):

Name of Student(s) committing act of alleged Harassment, Intimidation and Bullying (HIB):

Describe the incident being reported. What was the motivation behind this conflict?

How did you learn that student(s) may have been target(s) of HIB? Please be specific and include Name of other person(s) that

may know about this incident.

What was the location of the alleged HIB incident?

__ Location on school property:

__ Name/date of school sponsored function:

__ School Bus Incident (explain):

__ Off school grounds (explain):

__ Electronic Communication (cell phone, social media, etc.)

What harm do you believe was or may have been caused by the alleged incident?

You may choose to submit this report anonymously. Please note, in accordance with the Anti‐Bullying Bill of Rights Act, no formal

action is permitted on the basis of anonymous reporting alone.

Name and Signature of Person Reporting: ___________________________________________ Date: ___________________

Hib Incident Report Form

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