HIB Incident Form - To Be Completed by LEA Logo

  • HIB 338 Form
    Harassment, Intimidation, or Bullying (HIB)
    Mandatory Reporting Form
    2024-2025 School Year
    To Be Completed by Designated Local Educational Agency (LEA) Personnel

  • All allegations of HIB must be reported in writing and submitted to the principal within two school days from when a school employee or contracted service provider, witnesses or receives reliable information, that a student has been subject to HIB. A written statement from the alleged victim or other evidence may be attached to the back of this HIB 338 Form (e.g., screenshot, text thread, etc.).

    • The use of this form for reporting incidences of HIB is required.
    • This form shall be completed even if a preliminary determination is made under the LEA’s policy that thereported incident or complaint is a report outside the scope of the definition of HIB.
    • Required investigative procedures shall continue after the submission of this form to the school principal.
    • Principals are required to inform parents of all students involved in the alleged incident and keep a written record of the date, time, and manner of notification to parents.
    • The completed form must be kept on file in the school.
    • The principal must promptly submit a copy of this form to the superintendent.

     

    Directions
    Complete the form below to provide detailed information of the alleged HIB incident. If fields are not applicable or if the completing party is uncertain of the response, those fields may be left blank.

  • School Information

  • Individual Completing Form

  • Incident Information

  •  / /

  • Alleged Offender(s)

  • Alleged Victim(s)

  • Witnesses

    Complete this section with the names of any potential witnesses.

  • Alleged Bullying Behavior(s)

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

  • Signature

    Select the statement(s) that best describes the alleged bullying behavior (Check all that apply).
  • Clear
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  • HIB 338 Form
    Harassment, Intimidation, or Bullying (HIB)
    Mandatory Reporting Form
    2024-2025 School Year
    To Be Completed by Designated Local Educational Agency (LEA) Personnel

  • School Principal Section

    To be Completed by the School Principal

  • 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

  • Principal/Designee

  • HIB 338 Form
    Harassment, Intimidation, or Bullying (HIB)
    Mandatory Reporting Form
    2024-2025 School Year
    To Be Completed by Designated Local Educational Agency (LEA) Personnel

  • Superintendent Section

    To be Completed by the Superintendent

  • 1.Question for the School Principal/Designee
    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

  • If the answer to question 1 is no, follow your school district’s policies for HIB investigations and maintain a copy of this form.

  • Superintendent

  • HIB 338 Form
    Harassment, Intimidation, or Bullying (HIB)
    Mandatory Reporting Form
    2024-2025 School Year
    To Be Completed by Designated Local Educational Agency (LEA) Personnel

  • HIB 338 Report for the Superintendent

  •  
     
      HIB 338  
     
    Date and Time Received {dateAnd}
    Incident #  {typeA98}
    School District {schoolDistrict}
    School {typeA}
    Name of individual completing this form {nameOf}
    Role of individual completing the form {roleOf}
    Phone Number {phoneNumber}
    Email {email}
    Incident Date {incidentDate}
    Approximate time of the incident {approximateTime}
    Describe the incident with as much detail as possible. (What was the incident? Who was involved in the incident? How you were made aware of the incident? What happened at the time of the incident? How did the incident occur?) {describeThe}
    Specific incident location(s) (e.g., on the morning school bus, in the science wing hallway, online via social media, etc.) {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) {namesOf70}
    Based on your knowledge, select all that apply about the alleged victim(s) {basedOn71}
    Student Names {studentNames}
    Staff Names {staffNames}
    Parent Names {parentNames}
    Other Names (specify title or position for each) {otherNames}
    Select the statement(s) that best describes the alleged bullying behavior (Check all that apply). {basedOn79}
    Date {date}
    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? Check one below and submit this form to the Superintendent. {1Was}
    Comments (Optional) {commentsoptional}
    Principal/Designee's Name {principaldesigneesName}
    2. Questions 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? Check one and proceed as directed. {1Was93}
    Comments (Optional) {commentsoptional94}
    Superintendent's Name {superintendentsName}
    		 
     

  • For your reference, the reporting ID for this HIB 338 Form is: {incident}

  • Clear
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  • Should be Empty: