HIB 338 Form (HIB) Mandatory Reporting Form 2022-23 School Year For Staff

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.
School Information
School District:*
School:*
Individual Completing Form
If you prefer to remain anonymous, leave this section blank.
Name of individual completing this form
Role of individual completing the form:
e.g., teacher, lunchroom monitor, school bus driver, etc
Phone number
Email address

Confirmation Emailexample@example.com

Incident Information
Incident date (mm/dd/yyyy)*

MonthDayYear
Date
Approximate Time of the Incident*

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 you were 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):*
Alleged Bullying Behavior(s)
Select the statements that best describes the alleged bullying behavior Check all that apply*

Verbal e.g., teasing, name calling, derogatory comments, etcEmotional e.g., group exclusion, spreading rumors, taking belongings, etcPhysical e.g., hitting, pushing, inappropriate touching, etcElectronic e.g., attacking through social media, cyberbullying, offensive messaging, etc

School Principal/Designee and Superintendent Section
To be Completed by School Principal/Designee and Superintendent

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
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
Incident Tracking
If your school district utilizes a tracking system to track alleged incidents of HIB, insert the incident number below. *
Incident number
URL Capture
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HIB 338 Form Harassment, Intimidation, or Bullying (HIB) Mandatory Reporting Form 2022-23 School Year