Harassment, Intimidation or Bullying (HIB) Incident Reporting Form

The district is committed to a safe, civil educational environment for all students that is free from harassment, intimidation and bullying. Complete this form to report an incident.

Questions? Contact your school principal, counselor, a trusted adult or CVSD District Compliance Officer (Title IX, Civil Rights, Gender Equity, HIB) Tricia Campbell at 509-558-6561 or tcampbell@cvsd.org

Your name (optional):

You may remain anonymous.

Answer required for "Your name (optional):"

Phone number (optional):

If you would like contacted for additional information.

Number Required

Invalid phone number

Email (optional):

If you would like contacted for additional information.

Answer required for "Email (optional):"

Invalid email address

Targeted student(s) / victim(s):

Answer required for "Targeted student(s) / victim(s):"

Name of school adult contacted (if any):

Answer required for "Name of school adult contacted (if any):"

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

Answer required for "Name(s) of alleged aggressor(s) (if known):"

Incident(s) date(s) and time(s) (if known):

Answer required for "Incident(s) date(s) and time(s) (if known):"

Was law enforcement contacted in regard to this incident?

Answer required for "Was law enforcement contacted in regard to this incident?"

Yes

Unsure

Are the parents/guardians of the alleged victim(s) aware of this incident?

Answer required for "Are the parents/guardians of the alleged victim(s) aware of this incident? "

Yes

Unsure

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

Answer required for "Why do you think the harassment, intimidation or bullying occurred?"

Were there any witnesses/bystanders?

Answer required for "Were there any witnesses/bystanders?"

Yes

Not Sure

If yes, please provide witness/bystander names:

Answer required for "If yes, please provide witness/bystander names:"

Did a physical injury(ies) result from this incident(s)?

Answer required for "Did a physical injury(ies) result from this incident(s)?"

Yes

Not sure

If yes, please describe the injury(ies).

Answer required for "If yes, please describe the injury(ies)."

Was the targeted student(s) / victim(s) absent from school as a result of the incident(s)?

Answer required for "Was the targeted student(s) / victim(s) absent from school as a result of the incident(s)?"

Yes

If yes, please describe the absence.

Answer required for "If yes, please describe the absence."

Are there any notes, pictures, videos, texts, screen shots or other evidence of the incident(s)?

If yes, please include below.

Answer required for "Are there any notes, pictures, videos, texts, screen shots or other evidence of the incident(s)?"

You may upload any file(s) here.

Answer required for "You may upload any file(s) here. "

Choose a file or drag it here.

What additional information can you provide about the incident(s)?

Answer required for "What additional information can you provide about the incident(s)?"

Thank you for submitting the CVSD HIB Incident Reporting form.

HIB Incident Reporting Process:

Submittal of the HIB Reporting Form.
The report will be shared with the school principal at the school your student attends, or district staff as appropriate.
The school principal will review and investigate the incident, or district staff when appropriate. They will contact you within two (2) school days of receiving this report to discuss your concerns and gather additional information.
Investigations are usually completed within five (5) school days, unless additional time is needed. You will be contacted when the investigation is complete and/or if additional time is needed to fully investigate the incident.
Depending upon the frequency and severity of the conduct, intervention, counseling, correction, discipline, and/or referral to law enforcement will be used to remediate the impact on the victim and the climate and change the behavior or the perpetrator. The district will consider the frequency of incidents, developmental age of the student, and severity of the conduct in determining intervention strategies.

Harassment, Intimidation or bullying Information:

Central Valley is committed to a safe, civil educational environment for all students that is free from harassment, intimidation or bullying.

Definition of Harassment, Intimidation or Bullying:

Any intentionally written message or image, including those that are electronically transmitted, a verbal, or physical act including but not limited to one shown to be motivated by race, color, religion, ancestry, national origin, gender, sexual orientation or mental or physical disability (RCW 9A.36.080(3)) or any other distinguishing characteristic such as physical appearance, clothing or other apparel, socioeconomic status, gender identity and marital status when an act:

Physically harms a student or damages the student's property at school; or
Has the effect of substantially interfering with a student's education; or
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

Harassment, intimidation or bullying can take many forms including slurs, rumors, jokes, innuendos, demeaning comments, drawings, cartoons, pranks, gestures, physical attacks, threats or other written, oral, physical or electronically transmitted messages or images. False reports or retaliation for harassment, intimidation or bullying also constitute violations of CVSD Board Policy 3207.

CVSD Compliance Officer:

Tricia Campbell

2218 N. Molter Road, Liberty Lake, WA 99019

509-558-6561 or tcampbell@cvsd.org

Additional HIB info at www.cvsd.org/bullying

Please fix the highlighted areas below before submitting.

Harassment, Intimidation or Bullying (HIB) Incident Reporting Form