HIB Reporting Form

Directions: Harassment, intimidation, and bullying will not be tolerated in the Berlin Borough School District. Complete this form to report alleged harassment, intimidation, or bullying that occurred on school property; at a school-sponsored event or activity off of school property; on a school bus; on the way to/from school, or through any means of electronic communication (cell phone/e-mail/internet/pager,) in the current school year. Please do not include your name if you wish to remain anonymous. All responses will be kept confidential.

	Today's Date*
	mm/dd/yyyy

Person Reporting Incident: (Optional to remain anonymous)

Name:
Telephone:
Email:

Person Reporting Incident:*
Select at least 1 and no more than 1.

Student

Student (Witness/Bystander)

Parent/Guardian

Close Adult Relative/Friend

School Staff

Other, please specify

Student Victim Information:*

Name:
Age:

Alleged Offender(s) Information:*

Name/Age if known:
Name/Age if known:
Name/Age if known:
Name/Age if known:
Name/Age if known:

On what date(s) and times(s) did the incident happen?*

Date/time:
Date/time:
Date/time:
Date/time:

Where did the incident happen? (Choose all that apply)*
Select at least 1 and no more than 5.

On school property

On the way to/from school

At a school sponsored activity or event off of school property

On a school bus

On internet/cell phone/email or other electronic communication

	Did a physical injury result from this incident?*
	Did a physical injury result from this incident?* No Yes, but it did not require medical attention Yes, and it required medical attention

	Was the student victim absent from school as a result of this incident?*
	Was the student victim absent from school as a result of this incident?* Yes No No, but the student was fearful of returning to school

	If yes, how many days was the student victim absent from school as a result of the incident?

	Please describe, in as much detail as possible, what happened:*

	Do you know of any witnesses? If so, please provide as much detail as possible about these people. If not, please enter "no known witnesses."*

	Please use the space below to provide any additional information (optional):