"Harassment, Intimidation or Bullying (Hib) Incident Reporting Form - Northshore School District"

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Northshore
Student Services
School District
3207 F
Harassment, Intimidation or Bullying (HIB) Incident Reporting Form
Please read the definition below to determine if the behavior could be considered HIB:
Harassment, Intimidation, or Bullying (HIB) — is an intentional electronic, written, verbal, or physical act that:
• Physically harms a student or damages the student’s property.
• Has the effect of substantially interfering with a student’s education.
• Is so severe, persistent, or pervasive that it creates an intimidating or threatening educational environment.
• Has the effect of substantially disrupting the orderly operation of the school.
Conduct that is “substantially interfering with a student’s education” will be determined by considering a targeted student’s grades,
attendance, demeanor, interaction with peers, participation in activities, and other indicators.
Today’s date ____________________________
Reporting person (optional) _________________________________________
Targeted student(s) ___________________________________________________________________________________________
Your email address & phone number (optional) ____________________________________________________________________
Name of school adult you have already contacted (if any) ____________________________________________________________
Name(s) of alleged aggressor(s) or description (if known) ____________________________________________________________
_______________________________________________________________________________________________________
On what dates and periods did the incident(s) happen (if known) _______________________________________________________
_______________________________________________________________________________________________________
Where did the incident happen? Circle all that apply.
Auditorium
Cafeteria
Cell Phone
Classroom
Courtyard
Hallway
Internet
Library
Locker Room
Off School Property
Parking Lot
Playground
Restroom
School Bus
Sport Field
Stairway
Work/Store Room
_______________________________________________________________________
Other (Please describe)
Please check the box that best describes what the bully did. Please choose all that apply.
q
Hitting, kicking, shoving, spitting, hair pulling or throwing something at the student
q
Getting another person to hit or harm the student
q
Teasing, name calling, making critical remarks or threatening in person, by phone, by e-mail, etc.
q
Putting the student down and making the student a target of jokes
q
Making rude and/or threatening gestures
q
Excluding or rejecting the student
q
Making the student fearful, demanding money or exploiting
q
Spreading harmful rumors or gossip
q
Cyber bullying (bullying by calling, texting, emailing, web posting, etc.)
q
Other
If you select other, please describe _______________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
(continued on back side)
Student Services front (FC/vl 11/02/2011)
Northshore
Student Services
School District
3207 F
Harassment, Intimidation or Bullying (HIB) Incident Reporting Form
Please read the definition below to determine if the behavior could be considered HIB:
Harassment, Intimidation, or Bullying (HIB) — is an intentional electronic, written, verbal, or physical act that:
• Physically harms a student or damages the student’s property.
• Has the effect of substantially interfering with a student’s education.
• Is so severe, persistent, or pervasive that it creates an intimidating or threatening educational environment.
• Has the effect of substantially disrupting the orderly operation of the school.
Conduct that is “substantially interfering with a student’s education” will be determined by considering a targeted student’s grades,
attendance, demeanor, interaction with peers, participation in activities, and other indicators.
Today’s date ____________________________
Reporting person (optional) _________________________________________
Targeted student(s) ___________________________________________________________________________________________
Your email address & phone number (optional) ____________________________________________________________________
Name of school adult you have already contacted (if any) ____________________________________________________________
Name(s) of alleged aggressor(s) or description (if known) ____________________________________________________________
_______________________________________________________________________________________________________
On what dates and periods did the incident(s) happen (if known) _______________________________________________________
_______________________________________________________________________________________________________
Where did the incident happen? Circle all that apply.
Auditorium
Cafeteria
Cell Phone
Classroom
Courtyard
Hallway
Internet
Library
Locker Room
Off School Property
Parking Lot
Playground
Restroom
School Bus
Sport Field
Stairway
Work/Store Room
_______________________________________________________________________
Other (Please describe)
Please check the box that best describes what the bully did. Please choose all that apply.
q
Hitting, kicking, shoving, spitting, hair pulling or throwing something at the student
q
Getting another person to hit or harm the student
q
Teasing, name calling, making critical remarks or threatening in person, by phone, by e-mail, etc.
q
Putting the student down and making the student a target of jokes
q
Making rude and/or threatening gestures
q
Excluding or rejecting the student
q
Making the student fearful, demanding money or exploiting
q
Spreading harmful rumors or gossip
q
Cyber bullying (bullying by calling, texting, emailing, web posting, etc.)
q
Other
If you select other, please describe _______________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
(continued on back side)
Student Services front (FC/vl 11/02/2011)
Harassment, Intimidation or Bullying (HIB) Incident Reporting Form — page 2
Why do you think the harassment, intimidation or bullying occurred? ___________________________________________________
_______________________________________________________________________________________________________
q
q
Were there any witnesses?
Yes
No
If yes, please provide their names _______________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Did a physical injury result from this incident? If yes, please describe __________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
q
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)
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