Harassment, Intimidation, or Bullying Incident Reporting Form

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Once this form is submitted information will be sent to the Catalyst: bremerton HIB coordinator. They will look into the situation and get back to you if your contact information is listed in the form.

Reporting Person (First and Last Name) - optional

Targeted Student(s) (First and Last Name) *

Your email address- optional

Your phone number - optional

Name of School Adult You Have Already Contacted (if any)

Name(s) of students involved (if known)

On what date(s) did the incident(s) occur (if known)

What was the specific location of the incident(s)? Check all that apply.

Classroom

Commons/Cafeteria

Hallway

Parking Lot

Play area/recess yard

School bus

Playground

Off campus

Other:

Check the box(es) that best describe what the person did to you or your scholar.

Hitting, kicking, shoving, spitting, pulling hair

Getting another person to cause harm to you or your scholar

Name calling or making threatening or critical remarks

Making rude and/or threatening gestures

Excluding the student

Spreading harmful rumors or gossip

Cyber Bullying

Other:

Why do you think the harassment, intimidation, or bullying occurred (if known)?

List any information about possible witnesses.

Did a physical injury result from this incident?

Yes

Clear selection

Has the target missed school as a result of this incident?

Yes

Clear selection

Provide any additional information here.

Submit

Clear form

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