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 Families / Caregivers
This form should be used by parents or guardians to report allegations of HIB. Once the form is received by the school,the principal is responsible for implementing the school district’s policy and procedures. An investigation shall becompleted as soon as possible, but not later than 10 school days from the date of the written report of the incident.Should you have any questions about the investigation, please contact the school principal.
Directions
Complete the form below to provide detailed information of the alleged HIB incident. If some fields are not applicableor if you are uncertain of the response, you may skip those fields. This form may be submitted anonymously.
School Information
School District:*
School:*
Individual Completing Form
If you prefer to remain anonymous, leave this section blank.
Name of individual completing this form
Relation to individual completing this 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):*

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

To Be Completed by Families / Caregivers

Directions

School Information

Individual Completing Form

Incident Information

Alleged Offender(s)

Alleged Victim(s)

Witnesses

School Principal/Designee and Superintendent Section

Utilization of Preliminary Determination Provision

Question for the School Principal/Designee

Question for the Superintendent

Incident Tracking