SSS 2022-23 HIB 338 FORM

 
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 HIB 338 Reporting Form 2022-23 

 

 
   
  HIB 338 Form
Harassment, Intimidation, or Bullying (HIB) 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 be completed 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 applicable or if you are uncertain of the response, you may skip those fields. This form may be submitted anonymously.

Form

School Information
   
1.
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2.
*
 
   
  Individual Completing Form
(if you prefer to remain anonymous, leave this section blank.)
   
3.
 
   
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  Incident Information
   
7.
 
   
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10.
 
   
  Alleged Offender(s)
   
11.
 
   
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  Alleged Victim(s)
   
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  Witnesses
Complete this section with the names of any potential witnesses.
   
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  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 orcomplaint is a report outside the scope of the definition of HIB?

Yes

No


Question for the Superintendent

2.If the answer to question 1 is yes, will you require the school principal/designee to initiate an HIBinvestigation based on the scope of the definition of HIB?

Yes

No


Incident Tracking

If your school district utilizes a tracking system to track alleged incidents of HIB, insert the incident number.

Incident number:

   
 
 
 
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