Harassment, Intimidation or Bullying (Hib) Incident Reporting Form - Washington

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Washington State Harassment, Intimidation or Bullying (HIB)
Sample Incident Reporting Form
Reporting person (optional): ___________________________________________________________________
Targeted student: ____________________________________________________________________________
Your email address (optional): __________________________________________________________________
Your phone number (optional): ______________________Today’s date: _______________________________
Name of school adult you’ve already contacted (if any): _____________________________________________
Name(s) of aggressor(s) (if known):
___________________________________________________________________________________________
On what dates did the incident(s) happen (if known):
___________________________________________________________________________________________
Where did the incident happen? Circle all that apply.
Classroom
Hallway
Restroom
Playground
Locker room
Lunchroom/Cafeteria
Sport field
Gym
Parking lot
School bus
Online/Internet
Cell phone
During a school activity
Off school property
On the way to/from school
Other (Please describe.) _______________________________________________________
Please check the box that best describes what the bully did. Please choose all that apply.
Blocked movement
Gestures (Explain)
Racial slur(s)
Damage to my property
Gossip
Repeated behavior
Derogatory comments
Intimidation directed at me
Sexual stories/jokes/pictures
Disrespectful comments
Name calling
Sexual Orientation Slurs
Electronic / Cyberbullying
Offensive writing or graffiti
Slurs, rumors, jokes
Excluding me from activities
Physical harm or threats of harm
Spreading rumors
Hazing (Club, team, class, other)
Pranks
Threats (to me, friends, school)
Gender slurs
Put downs
Touching / grabbing
Other: (Please describe.)
Washington State Harassment, Intimidation or Bullying (HIB)
Sample Incident Reporting Form
Reporting person (optional): ___________________________________________________________________
Targeted student: ____________________________________________________________________________
Your email address (optional): __________________________________________________________________
Your phone number (optional): ______________________Today’s date: _______________________________
Name of school adult you’ve already contacted (if any): _____________________________________________
Name(s) of aggressor(s) (if known):
___________________________________________________________________________________________
On what dates did the incident(s) happen (if known):
___________________________________________________________________________________________
Where did the incident happen? Circle all that apply.
Classroom
Hallway
Restroom
Playground
Locker room
Lunchroom/Cafeteria
Sport field
Gym
Parking lot
School bus
Online/Internet
Cell phone
During a school activity
Off school property
On the way to/from school
Other (Please describe.) _______________________________________________________
Please check the box that best describes what the bully did. Please choose all that apply.
Blocked movement
Gestures (Explain)
Racial slur(s)
Damage to my property
Gossip
Repeated behavior
Derogatory comments
Intimidation directed at me
Sexual stories/jokes/pictures
Disrespectful comments
Name calling
Sexual Orientation Slurs
Electronic / Cyberbullying
Offensive writing or graffiti
Slurs, rumors, jokes
Excluding me from activities
Physical harm or threats of harm
Spreading rumors
Hazing (Club, team, class, other)
Pranks
Threats (to me, friends, school)
Gender slurs
Put downs
Touching / grabbing
Other: (Please describe.)
Why do you think this 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 targeted student absent from school as a result of the incident?
Yes
No
If yes, please describe
___________________________________________________________________________________________
Are there any notes, pictures, texts, screen shots or other evidence of the event(s) you are reporting?
__________________________________________________________________________________________
__________________________________________________________________________________________
Is there any additional information you can add?
___________________________________________________________________________________________
___________________________________________________________________________________________
Thank you for reporting!
----------------------------------------------------------------For Office Use----------------------------------------------------------------
Received by: _______________________________________________________________________________
Date received: ___________________________________
Action taken: ______________________________________________________________________________
Parent/guardian contacted: ___________________________________________________________________
Circle one:
Resolved
Unresolved
Referred to: _____________________________________

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