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Report Harassment, Intimidation, or Bullying (online form)
Report Harassment, Intimidation, or Bullying (online form)
Please complete the form below. Required fields marked with an asterisk *
Centralia School District
Harrassment, Intimidation or Bullying (HIB)
Incident Reporting Form
Today's Date
*
Answer Required
Building
*
Answer Required
This is a(n)
Answer Required
Confidential Report
Anonymous Report
Non-Confidential Report
Third Party Report
Reporting Person (optional)
Answer Required
Targeted student(s)
*
Answer Required
Your email address (optional)
Answer Required
Your phone number (optional)
Number Required
Name of school adult you've already contacted (if any)
Answer Required
Name(s) of bully(ies) (if known)
Answer Required
On what date(s)/time of day did the incident(s) happen (if known)
Answer Required
Where did the incident(s) happen?
*
Answer Required
Classroom
Hallway
Restroom
Playground
Locker Room
Lunch Room
Sports Field
Parking Lot
School Bus
Internet
Cell Phone
During a School Activity
On The Way To/From School
School Bus Stop
Off School Property
Other:
Please check the box that best describes what the bully did. Please choose all that apply.
Answer Required
Hitting, kicking, shoving, spitting, hair pulling or throwing something at the student
Getting another person to hit or harm the student
Testing, name calling, making critical remarks or threatening in person, by phone, by email, etc.
Putting the student down and making the student a target of jokes
Making rude and/or threatening gestures
Inappropriate touch
Making the student fearful, demanding money or exploiting
Spreading harmful rumors or gossip
Cyberbullying (bullying by calling, texting, emailing, web posting, etc.)
Other:
If you selected Other, please describe:
Answer Required
Why do you think the harassment, intimidation or bullying occurred?
Answer Required
How did you, the reporter, address/handle this incident?
Answer Required
Were there any witnesses?
Answer Required
Yes
No
If yes, please provide their names:
Answer Required
Did a physical injury result from this incident?
Answer Required
Yes
No
If yes, please describe:
Answer Required
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