Curlew School District 50

School Forms

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
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