Harassment, Intimidation, & Bullying Incident Report Form
Please use this form to report an incident of harassment, intimidation, or bullying that you witnessed or received reliable information about.
Name of School:
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Name of person making this report:
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Relationship to the affected person:
Name of Affected: *
State name and grade (if applicable) of affected person.
Your answer
Name of alleged accused: *
State name and grade (if applicable) of alleged accused person
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List any witnesses to this incident:
List name(s) and grade(s) of witnesses
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Date of the incident:
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Approximate time:
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Where did the incident occur?
Check which best describes the alleged harassment, intimidation, and/or bullying (HIB) behavior the target was subjected to:
Identify what harm you believe was or may have been caused by the alleged incident. Check all that apply:
Describe the incident
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