HIB 338 Form: District Personnel

 
 
  

HIB 338 Form
Harassment, Intimidation, or Bullying (HIB)
Mandatory Reporting Form
2022-23 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.

  • 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 the reported 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.
  • 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.


 

 
 

Individual Completing Form

If you prefer to remain anonymous, leave this section blank.


   
 
 
   
 
 
   
 
 
   
 
 
   

 
 

Incident Information


   
 
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  Select Date
mm/dd/yyyy
   
 
 
   
 
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Alleged Offender(s)


   
 
 
   
 
 
  
  
  
  
   

 
 

Alleged Victim(s)


   
 
 
   
 
 
  
  
   

 
 

Witnesses

Complete this section with the names of any potential witnesses


   
 
 
   
 
 
   
 
 
   
 
 
   

 
 

Alleged Bullying Behavior(s)


   
 
 
  
  
  
  
   
 
 
 
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