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HIB Anonymous Report _doc_ - Manville School District.doc

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					                                             Anonymous Report
                                   for Harassment, Intimidation and Bullying

Date of Alleged Incident                        School                                Today’s Date

      Describe the nature of alleged harassment, intimidation or bullying. Include any gesture, any relevant
      written, verbal or physical act(s), or any electronic communication (use back of form for additional
      space).




      Location of alleged HIB incident. Check all that apply and specify/describe location:

             School property:
             School-sponsored function:
             School bus:
             Off school grounds:


      Was someone supervising when the incident occurred?

                                                      student    parent    staff    other (_____________)
                                                      student    parent    staff    other (_____________)
                                                      student    parent    staff    other (_____________)
                                                      student    parent    staff    other (_____________)



      List below any person who you know or have reason to believe may have relevant information and
      indicate if student, parent, staff member or other.

                                                      student    parent    staff    other (_____________)
                                                      student    parent    staff    other (_____________)
                                                      student    parent    staff    other (_____________)
                                                      student    parent    staff    other (_____________)

				
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posted:12/19/2012
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