• Curlew School Harassment, Intimidation or Bullying (HIB)

    Incident Reporting Form

     

    Harassment, intimidation or bullying  means any intentionally written message or image including those that are electronically
     transmitted, verbal, or physical act, including but not limited to one shown to be motivated by race, color, religion, ancestry,
    national origin, gender, sexual orientation gender expression or identity, mental or physical disability or other distinguishing
    characteristics, when an act:
     
                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 is creates an intimidating or threatening educational environment.

               Has the effect of substantially disrupting the orderly operation of the school.

     

    Type of Report (Please check only one)                Anonymous             Confidential            Non-Confidential

    Reporting person (optional): ___________________________________________________________________

    Targeted student: ____________________________________________________________________________

    Your email address (optional):__________________________________________________________________

    Your phone number (optional):____________________________ Today's date: __________________________

    Name(s) of alleged bullies (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          Sport field

    Parking lot          School bus           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.

                    Hitting, kicking, shoving, spitting, hair pulling or throwing something at the student

                    Getting another person to hit or harm the student

                    Teasing, name calling, making critical remarks or threatening in person, by phone, by e-mail, etc.

                    Putting the student down and making the student a target of jokes

                    Making rude and/or threatening gestures

                    Excluding or rejecting the student

                    Making the student fearful, demanding money or exploiting

                    Spreading harmful rumors of gossip

                    Cyber bullying (bullying by calling, texting, emailing, web posting, etc.)

                    Other

     

    Please describe the incident _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

     

    Why do you think the harassment, intimidation or bullying 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 target absent form 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: _____________________________________________________________________________________________

     

    Dave received: ___________________________________________________________________________________________

     

    Action Taken: ____________________________________________________________________________________________

     

    Parent/guardian contacted: ________________________________________________________________________________

     

    Circle one:          Resolved            Unresolved

     

    Referred to:  _______________________________

     
Last Modified on January 17, 2013