HIB 338 Form
Harassment, Intimidation, or Bullying (HIB)
Mandatory Reporting Form
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. A written statement from the alleged victim or
other evidence may be attached to the back of this HIB 338 Form (e.g.,
screenshot, text thread, etc.).
•
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.
•
Principals are required to inform parents of all students involved in the
alleged incident and keep a written record
of the date, time, and manner of notification to parents.
• 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 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:
Page 1 of 4
Incident Information
Incident date (mm/dd/yyyy):
Approximate time of the incident:
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.
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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 statement(s) that best describes the alleged
bullying behavior (Check all that apply).
Verbal (e.g., teasing, name calling,
derogatory comments, etc.)
Emotional (e.g., group exclusion,
spreading rumors, taking belongings, etc.)
Physical (e.g., hitting, pushing,
inappropriate touching, etc.)
Electronic (e.g., attacking through
social media, cyberbullying, offensive messaging, etc.)
Signature
Signature of person completing this HIB 338
Form:
Date:
Page 3 of 4
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.
1. Question for the School Principal/Designee
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? Check one below and submit
this form to the Superintendent.
Yes - Follow your school
district’s policies for other reports (e.g., code of student conduct, referral
to counseling services, etc.)
No- Refer to your school
district’s HIB policy for initiating an HIB investigation.
Comments (Optional):
2. Question for the Superintendent
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? Check one and proceed as directed.
Yes- Notify the principal of
this determination in writing and direct the principal to initiate an HIB
investigation per the district’s policy.
No- Follow your school
district’s policies for other reports (e.g., code of student conduct, referral
to counseling services, etc.) and maintain a copy of this form.
If the answer to question 1 is no, follow your school
district’s policies for HIB investigations and maintain a copy of this
form.
Comments (Optional):
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