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NOTE:

For official copies of board policies and procedures please contact the superintendent's office at (253) 583-5190 or email supt@cloverpark.k2.wa.us

Harassment, Intimidation or Bullying (HIB) Incident Reporting Form
3207-F1

School:

Reporting person (optional):

Targeted student:

Your e-mail address (optional):

Your phone number (optional): Today's date:

Name of adult at school you've already contacted (if any):

Name(s) of alleged aggressor(s) if known (the bully):

On what dates did the incident(s) happen: (if known):

Where did the incident(s) happen (if known):







Please check the box that best describes what the bully did. Please choose all that apply.










If you selected other, please describe:

Why do you think the harassment, intimidation or bullying occurred?

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

Did a physical injury result from this incident? If yes, please describe.

Was the targeted student absent from school as a result of the incident? If yes, please describe:

Is there any additional information?

Thank you for reporting!


For Office Use

Received by:

Date received:

Action taken:

Parent/guardian contacted:

Check one:

Referred to: