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Washington State Harassment, Intimidation, or Bullying (HIB) Incident Reporting Form
Harassment, intimidation, or bullying means an intentional electronic, written, verbal, or physical act that: (1) physically harms a student or damages the student's property; (2) has the effect of substantially interfering with a student's education; (3) is so severe, persistent, or pervasive that it creates an intimidating or threatening educational environment; or (4) has the effect of substantially disputing the orderly operation of the school as measured by grades, attendance, demeanor, interaction with peers, participation in activities, and other indicators.
Email address *
Reporting person (optional):
Your answer
Targeted student: *
Your answer
Your email address (optional):
Your answer
Your phone number (optional):
Your answer
Today's date *
Your answer
Name of school adult you have already contacted (if any): *
Your answer
Name(s) of aggressor(s): *
Your answer
On what dates did the incident(s) happen: *
Your answer
Where did the incident happen (check all that apply)? *
Required
Please check the box that best describes what the aggressor did. Please choose all that apply *
Required
Why do you think this occurred? *
Your answer
Were there any witnesses? If yes, please provide their first and last names. *
Your answer
Did a physical injury result from this incident? If yes, please describe. *
Your answer
Was the targeted student absent from school as a result of the incident? If yes, please describe. *
Your answer
Are there any notes, pictures, texts, screen shots, or other evidence of the event(s) you are reporting? *
Your answer
Is there any additional information you can add? *
Your answer
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