Vista Middle School -HIB Incident Reporting Form

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The Ferndale School District takes bullying very seriously and has a zero-tolerance policy. In order to protect our students from bullying, it is important that we partner with families to properly identify bullying and work together to come up with solutions that stop the bullying behavior and support all students involved. (Board Policy 3207)

Email *

Record my email address with my response

Harassment, Intimidation, Bullying (HIB) Reporting Form

All suspected harassment, intimidation, or bullying incidents are reported to the principal, dean, assistant principal, and/or school counselor, who then will do an investigation. If the incident is confirmed to be a case of bullying proper follow through will occur. It is important to note that not all incidents will result in a confirmed case of bullying. However, even if an incident is not confirmed to be bullying, it may still result in consequences and/or interventions for those involved.

Today's Date *

YYYY

Incident Date *

YYYY

Your Name *

Victim's Name *

Aggressor's Name *

Were there any witnesses? *

Yes

If there were witnesses what are their names?

Where did the incident happen? (Check all that apply) *

Classroom

Hallway

Restroom

Lunch Recess

Cafeteria

School bus

Internet/Cell phone

Off school property

School activity

Specialist class (PE, Music, other elective)

Other (Please describe)

Required

Please check the box that best describes what the bully did. (Choose all that apply) *

Hitting, kicking, shoving, spitting, hair pulling, or throwing something at the student

Getting another person to hit or harm the student

Teasing, name calling, or threatening in person, by phone, by email, etc.

Putting the student down and making the student a target of jokes

Making rude and/or threatening gestures

Excluding or rejecting the student

Making the student fearful, demanding money or a specific action

Spreading harmful rumors or gossip

Cyber bullying (calling, texting, emailing, web posting, social media, etc.)

Discriminatory Harrassment

Other:

Required

If you selected "other" above please explain below.

Why do you think harassment, intimidation, or bullying occurred? *

Did a physical injury result from this incident? *

Yes

If there was physical injury please describe

Was the target/victim absent from school as a result of the incident? *

Yes

Not sure

If the target/victim was absent as a result, please describe

Please briefly explain what has been happening

Submit

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