Families & Caregivers HIB Incident Form

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.

Directions


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.
Form
School Information
School District:
School:
Individual Completing Form
If you prefer to remain anonymous, leave this section blank.
Name of individual completing this form:
Relation to individual involved in alleged incident of HIB
(e.g., parent, guardian, grandparent, etc.):
Phone number:
Email address:
Incident Information
If you don’t know the answer please write in N/A where applicable.
Incident date 
MM
/
DD
/
YYYY
Approximate time of the incident:
Time
:
Describe the incident with as much detail as possible. (What was the incident? Who was involved in the incident? How you were made aware of the incident? What happened at the time of the incident? How did the incident occur?) 
Specific incident location(s) (e.g., on the morning school bus, in the science wing hallway, online via social media, etc.)
Alleged Offender(s)
If you don’t know the answer please write in N/A where applicable.
Name(s) of alleged offender(s): 
Based on your knowledge, select all that apply about the alleged offender(s): 
Alleged Victim(s)
If you don’t know the answer please write in N/A where applicable.
Name(s) of alleged victim(s): 
Based on your knowledge, select all that apply about the alleged victim(s):
Witness
Complete this section with the names of any potential witnesses. If you don’t know the answer please write in N/A where applicable.
Student Names:
Staff Names:
Parent Names:
Other Names (specify title or position for each):
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