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HIB 338 Community Form Harassment, Intimidation or Bullying (HIB) Form

HIB 338 Community Form Harassment, Intimidation or Bullying (HIB) Form

This form should be used by parents or guardians to report allegations of HIB. Once the form is received by the school, the principal is responsible for implementing the school district's policy and procedures. Should you have any questions, please contact the principal.

Your Name

Individual Completing this Form. (If you prefer to remain anonymous, leave this section blank.) Otherwise, please provide your name and relation to the individual involved in the alleged incident of and a contact phone number and email to reach you.

Answer required for "Your Name"

School*

Answer required for "School"

Martha B. Day

Samuel R. Donald

Walter T. Bergen

Who was/is bullied? (Name and Grade)*

Answer required for "Who was/is bullied? (Name and Grade)"

Who did/is doing the bullying? (Name and Grade)*

Answer required for "Who did/is doing the bullying? (Name and Grade)"

When did the bullying happen?*

Please provide the date and approximate time when this incident occurred.

Answer required for "When did the bullying happen?"

Where did the bullying happen?*

Answer required for "Where did the bullying happen?"

Please describe the incident in as much detail as possible (What was the incident? Who was involved? How were you made aware of the incident? How did the incident occur?)*

Answer required for "Please describe the incident in as much detail as possible (What was the incident? Who was involved? How were you made aware of the incident? How did the incident occur?)"