HIB Incident Form - To Be Completed by Families / Caregivers

Harassment, Intimidation, or Bullying (HIB) Reporting Form

To Be Completed by Families / Caregivers (2024-2025 School Year)
This form should be used by parents or guardians to report allegations of HIB. 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 10 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
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.
School Information
School District*
School*
Individual Completing Form
Do you prefer to remain anonymous?*
Name of individual completing this form

First NameLast Name
Relation to individual involved in alleged incident of HIB
(e.g., parent, guardian, grandparent, etc.):
Phone number
Email address
Incident Information

Please complete this section with as much detail as possible.
Incident date (if known)

MonthDayYear
Approximate time of incident (if known)

Hour Minutes

AM/PM Option
Describe the incident with as much detail as possible.*
What was the incident? Who was involved in the incident? How were you made aware of the incident? What happened at the time of the incident? How 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.)
Alleged Offender(s)
Name(s) of alleged offender(s)*
Based on your knowledge, 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.
Alleged Victim(s)
Name(s) of alleged victim(s)*
Based on your knowledge, select all that apply about the alleged victim(s):

Victim(s) attends the above-named school.Victim(s) attends another school.
Witnesses

Complete this section with the names of any potential witnesses.
Student Names
Staff Names
Parent Names
Other Names (specify title or position for each)
Signature
Signature of Person Completing this HIB 338 Form*

Clear
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option

Harassment, Intimidation, or Bullying (HIB) Reporting Form
School Principal/Designee Section

To be Completed by School Principal/Designee
Note: The completed form must be kept on file in the school. The principal must promptly submit a copy of this form to the superintendent.

Utilization of Preliminary Determination Provision
If the school district’s policy permits the use of a preliminary determination for reports of HIB, question 1 and 2 below must be completed on every form. School districts who do not permit the use of a preliminary determination for reports of HIB, should leave this section blank.
Question for the School Principal/Designee
1. Was a preliminary determination made not to initiate an HIB investigation because the reported incident or complaint is a report outside the scope of the definition of HIB?*

YesNo
School Principal/Designee Comments
Principal/Designee
Principal/Designee's Name*

First NameLast Name
Principal/Designee's Email*

Harassment, Intimidation, or Bullying (HIB) Reporting Form
Superintendent Section

To be Completed by the Superintendent
Question for the School Principal/Designee
1. Was a preliminary determination made not to initiate an HIB investigation because the reported incident or complaint is a report outside the scope of the definition of HIB? {1Was}
Question for the Superintendent
2. If the answer to question 1 is yes, will you require the school principal/designee to initiate an HIB investigation based on the scope of the definition of HIB?*

YesNo
Superintendent Comments
Superintendent
Superintendent's Name*

First NameLast Name
Superintendent's Email*

Harassment, Intimidation, or Bullying (HIB) Reporting Form
HIB 338 Report for the Superintendent


	HIB 338

Date and Time Received	{todaysDate}
Reporting ID	{uniqueId}
School District	{schoolDistrict}
School	{school}
Do you prefer to remain anonymous?	{doYou}
Name of individual completing this form	{nameOf}
Relation to individual involved in alleged incident of HIB	{relationTo}
Phone number	{phoneNumber}
Email address	{emailAddress}
Incident date (if known)	{incidentDate}
Approximate time of incident (if known)	{approximateTime}
Describe the incident with as much detail as possible.	{describeThe}
Specific incident location(s)	{specificIncident}
Name(s) of alleged offender(s)	{namesOf}
Based on your knowledge, select all that apply about the alleged offender(s)	{basedOn}
Name(s) of alleged victim(s)	{namesOf47}
Based on your knowledge, select all that apply about the alleged victim(s):	{basedOn48}
Student Names	{studentNames}
Staff Names	{staffNames}
Parent Names	{parentNames}
Other Names (specify title or position for each)	{otherNames}
1. Question for the School Principal/Designee
1. Was a preliminary determination made not to initiate an HIB investigation because the reported incident or complaint is a report outside the scope of the definition of HIB?	{1Was}
School Principal/Designee Comments	{schoolPrincipaldesignee95}
Principal/Designee's Name	{principaldesigneesName}
Principal/Designee's Email	{principaldesigneesEmail}
2. Question for the Superintendent
2. If the answer to question 1 is yes, will you require the school principal/designee to initiate an HIB investigation based on the scope of the definition of HIB?	{2If}
Superintendent Comments	{superintendentComments}
Superintendent's Name	{superintendentsName}
Superintendent's Email	{superintendentsEmail}

For your reference, the reporting ID for this HIB 338 Form is: {uniqueId}
Summary of Incident*
Staff/Student Consequence(s)*
Remedial Measure(s)*
Please select a HIB Status*
Staff Member's Name Completing this HIB 338 Form*

First NameLast Name
Email*
Signature of Person Completing this HIB 338 Form*

Clear
Date/Time*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

Harassment, Intimidation, or Bullying (HIB) Reporting Form

School Information

Individual Completing Form

Incident Information

Alleged Offender(s)

Alleged Victim(s)

Witnesses

Signature

Harassment, Intimidation, or Bullying (HIB) Reporting Form

School Principal/Designee Section

Question for the School Principal/Designee

Principal/Designee

Harassment, Intimidation, or Bullying (HIB) Reporting Form

Superintendent Section

Question for the Superintendent

Superintendent

Harassment, Intimidation, or Bullying (HIB) Reporting Form

HIB 338 Report for the Superintendent