School District of the Chathams - HIB 338 Form - To be completed by Families/Caregivers

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

This form should be used by parents or guardians to report allegations of HIB. A written statement from the alleged victim or other evidence may be attached to the back of this HIB 338 Form (e.g., screen shot, text thread, etc.). 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 ten 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: Please 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.

If you prefer to remain anonymous, leave this section blank. Individuals filling out this HIB 338 Form as an anonymous reporter may consider adding their name as a witness on Page 2.

Last Name:

First Name

Relation to individual involved in alleged HIB incident (e.g.,

Phone number:

Email address

School *

CHS

CMS

LAF

MAS

SBS

WAS

District

Other

Date of Incident

YYYY

Approximate time of incident

Where 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.) *

Describe the incident with as much detail as possible. *

What happened at the time of the incident? *

How did the incident occur? *

How were you made aware of the incident? *

Name (s) of alleged offender (s) *

Select all that apply about the alleged offender (s) *

Alleged offender (s) attends the above named school

Alleged offender (s) attends another school

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

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

Name (s) of alleged victim (s) *

Select all that apply about the alleged victim (s) *

Alleged victim (s) attends the above named school

Alleged victim (s) attends another school

List the name (s) of any potential witnesses

Student Names:

Staff Names:

Parent Names:

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

Alleged Bullying Behavior(s)

Select the statement(s) that best describes the alleged bullying behavior (Check all that apply).

Verbal (e.g., teasing, name calling, derogatory comments, etc.)

Emotional (e.g., group exclusion, spreading rumors, taking belongings, etc.)

Physical (e.g., hitting, pushing, inappropriate touching, etc.)

Electronic (e.g., attacking through social media, cyberbullying, offensive messaging, etc.)

Required

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of School District of the Chathams.

Does this form look suspicious? Report

Forms