Hib Incident Reporting Form (Page 2 of 2) in pdf

Harassment, Intimidation or Bullying (HIB) Incident Reporting Form — page 2

Why do you think the harassment, intimidation or bullying occurred? ___________________________________________________

_______________________________________________________________________________________________________

q

Were there any witnesses?

Yes

If yes, please provide their names _______________________________________

_______________________________________________________________________________________________________

Did a physical injury result from this incident? If yes, please describe __________________________________________________

_______________________________________________________________________________________________________

q

Was the target absent from school as a result of the incident?

Yes

No If yes, please describe ________________________

_______________________________________________________________________________________________________

Is there any additional information? ______________________________________________________________________________

_______________________________________________________________________________________________________

Thank you for reporting!

For Office Use

Received by _________________________________________________________

Date received _______________________

Action taken ________________________________________________________________________________________________

_______________________________________________________________________________________________________

Parent/Guardian contacted (name) _______________________________________________________________________________

How was Parent/Guardian contacted (i.e., phone; in person, mail)? _____________________________________________________

Date the Parent/Guardian was contacted __________________________________________________________________________

Circle one:

Resolved

Unresolved

Referred to _________________________________________________________________________________________________

Student Services back (FC/vl 11/02/2011)

Hib Incident Reporting Form Page 2