We've detected that Javascript is not enabled. It is required for an optimal survey taking experience.
Please check your browser's settings and make sure Javascript is turned on. Learn how to enable Javascript.

Skip survey header

HIB

Chief Leschi Schools Harassment, Intimidation & Bullying Form

Harassment, Intimidation, and Bullying is an intentional electronic, written, verbal or physical act that

Physically harms a student or damages that student’s property;
Has the effect of substantially interfering with a student’s education;
Is so severe, persistent or pervasive that it creates an intimidating or threatening educational environment; or
Has the effect of substantially disrupting the orderly operation of the school.

1. Reporting person (optional):

2. Date of incident:

3. Targeted student: *This question is required.

4. Your phone number (optional):

5. Name(s) of school staff you've already notified (if any)?

6. Name(s) of alleged bullies (if not known, then other identifying factors)

7. Please check the box(es) that best describe the harassment/intimidation/bullying. Select all that apply. *This question is required.

Please enter an 'other' value for this selection.

8. Where did the harassment/intimidation/bullying occur? Select all that apply: *This question is required.

Please enter an 'other' value for this selection.

9. Why do you think the harassment/intimidation/bullying occurred?

10. Were there any witnesses? If yes, please provide their names.

11. Did a physical injury result from the harassment/intimidation/bullying? If yes, describe:

12. Has the targeted student been absent from school as a result of the harassment/intimidation/bullying? If yes, describe:

13. How did you feel when you heard about the harassment/intimidation/bullying?

14. What can be done to make things right?

15. Would you be willing to participate in a circle conversation to help make things right?

16. Is there any additional information?