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TES Harassment, Intimidation and Bully Reports Form

Complete the form below to provide detailed information of the alleged HIB incident. If some fields are not applicable or if you are uncertain of the response, you may skip those fields. This form may be submitted anonymously.

This form should be used by parents or guardians to report allegations of HIB. Once the form is received by the school, the principal is responsible for implementing the school district's policy and procedures. An investigation shall be completed as soon as possible, but not later than 10 school days from the date of the written report of the incident. Should you have any questions about the investigation, please contact the school principal.

INDIVIDUAL COMPLETING FORM

Name of individual completing this form:

Answer Required

Relation to individual involved in alleged incident of HIB (e.g., parent, guardian, grandparent, etc.):

Answer Required

Phone Number:

Answer Required

Email Address:

Answer Required

INCIDENT INFORMATION

Incident Date:*

Answer Required

Approximate time of the incident:*

Answer Required

Describe the incident with as much detail as possible. (What was the incident? Who was involved in the incident? How were you made aware of the incident? What happened at the time of the incident? How did the incident occur?)*

Answer Required

Specific incident location(s) (e.g., on the morning school bus, in the science wing hallway, online via social media, etc.)*

Answer Required

ALLEGED OFFENDER(s)

Name(s) of alleged offender(s):*

Answer Required

Based on your knowledge, select all that apply about the alleged offender(s):*

Answer Required

Alleged offender(s) attends the above-named school.

Alleged offender(s) works for the school/school district.

Alleged offender(s) does not work for the school district.

ALLEGED VICTIM(s)

Name(s) of alleged victim(s):*

Answer Required

Based on your knowledge, select all that apply about the alleged victim(s):*

Answer Required

Victim(s) attends the above named-school.

Victim(s) attends another school.

WITNESSES

Student Names:*

Answer Required

Staff Names:*

Answer Required

Parent Names:*

Answer Required

Other Names (specify title or position for each):*

Answer Required