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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 electronicallytransmitted, 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 distinguishingcharacteristics, 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: _______________________________
