HIB Referral Forms

HIB Referral Forms

This form should be used to identify a possible incident of bullying or harassment. The person that observes the conduct or receives the complaint completes this form. Forward copies of the form to the building administrator within two days.

      Date (MM/DD/YYYY)
   
 

 


 

  NAME OF ALLEGED VICTIM
 Last Name
 First Name
 Grade of Alleged Victim
   
 

 


 

  REPORT BY
 Last Name
 First Name
 Position
 If other, please specify
   
 

 


 

  REPORTED TO
 Last Name
 First Name
 Position
 If other, please specify
   
 

 


 

   
 Best describe the nature of the conern or incident 
  
   
 

 


 

 Name/Contact information of possible witnesses 
  
 

 


 

 Check all of the actual or perceived characteristics that were or may have been motivational factors in the alleged H.I.B. incident
   
 If other (actual or perceived characteristic)  
   
 

 


 

 Identify what harm you believe was or may have been caused by the alleged incident.  Check all that apply.
   

 



Security Measure
Website by SchoolMessenger Presence. © 2017 West Corporation. All rights reserved.