Blaine School District
Harassment, Intimidation, or Bullying (HIB)
Incident Report Form
In order to protect a targets student from retaliation, a student need not reveal his identity on the Incident Report Form. The form
may be filed anonymously, confidentially, or the student may choose to disclose his or her identity (non-confidential).
Date: __________________
BASIC INFORMATION
Targeted Student: ________________________________________ Grade: ________
Person completing Incident Reporting Form:
Name: _________________________________________________ Phone: ________________________________
INFORMATION ABOUT THE INCIDENT
Individual(s) being reported: _________________________________________________________________________
Date of Incident: _____________________ Time: _______________________
Where the incident happened (check all that apply):
__Classroom __Hallway __Restroom __Playground __ Locker Room __ Lunchroom
__ Sport field __Parking lot __ School Bus __Internet __ Cell phone
__ During a school activity __Off school property __On the way to/from school
__ Other (describe): ________________________________________________________________
Check what best describes happened to the targeted Student (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, making critical remarks or threatening in person, by phone, 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 exploiting
__ Spreading harmful rumors or gossip
__ Cyber bullying (bullying by calling, texting, emailing, web posting, etc.)
Write a brief summary of the incident:__________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Name(s) of witness (if any): ___________________________________________________________________________
Did a physical injury result from this incident? If yes, please describe: ________________________________________
__________________________________________________________________________________________________
Any additional information: __________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
SCHOOL DISTRICT USE
Received By: ___________________________________________ Date Received: __________________________
Blaine School District ~ Policy & Procedure 3207 ~ Prohibition of Harassment, Intimidation & Bullying Incident Report Form June 25 2012
