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:
Name of person making this report:
Relationship to the affected person:
Name of Affected:
State name and grade (if applicable) of affected person.
Name of alleged accused:
State name and grade (if applicable) of alleged accused person
List any witnesses to this incident:
List name(s) and grade(s) of witnesses
Date of the incident:
Where did the incident occur?
On school property
At a school sponsored activity or event off school property
Check which best describes the alleged harassment, intimidation, and/or bullying (HIB) behavior the target was subjected to:
Physical Bullying (pushing, shoving, hitting, threats, vandalism, theft, etc.)
Emotional Bullying (name calling, insults, teasing, harassing phone calls/texts/I-Ms, etc.)
Social Bullying (gossiping, teasing about appearance, exclusion, public humiliation, etc.)
Cyber-Bullying (texting/messaging threats, defamatory web posts, derogatory emails, etc.)
Identify what harm you believe was or may have been caused by the alleged incident. Check all that apply:
Substantial disruption or interference with the orderly operation of school or rights of others
Physical or emotional harm
Insulting or demeaning a student or group of students
Creating a hostile educational environment
Describe the incident
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