HIB 338 Reporting Form

	Please complete all sections of this form. It will be submitted to the building principal via e-mail. Please note that formal disciplinary action may not be taken solely on the basis of an anonymous report.

	School Information

	School District - Delaware Valley Regional High School District

1.	Today's Date (mm/dd/yyyy):*
	mm/dd/yyyy

	Delaware Valley Regional High School

	Individual Completing Form

	If you prefer to remain anonymous, please leave this section blank.

2.	Name of the individual completing this form:

3.	Relation to the individual involved in an alleged incident of HIB (e.g. parent, guardian, grandparent, etc.):

4.	Phone Number:

5.	Email address:

	Incident Information

6.	Date of Alleged Incident Date (mm/dd/yyyy):*
	mm/dd/yyyy

7.	Approximate time of the incident:*

8.	Describe the incident with as much detail as possible. (What was the incident? Who was involved in the incident? How were you made aware of the incident? What happened at the time of the incident? How did the incident occur?)*

9.	Specific indent location(s) (e.g., on the morning school bus, in the science wing hallway, online via social media, etc.)*

	Alleged Offender(s)

10.	Name(s) of alleged offender(s):*

11.	Based on your knowledge, select all that apply about the alleged offender(s): *
	Alleged offender(s) attends the above-named school.    Alleged offender(s) attends another school.    Alleged offender(s) works for the school/school district.    Alleged offender(s) does not work for the school/school district.

	Alleged Victim(s)

12.	Name(s) of alleged victim(s):*

13.	Based on your knowledge, select all that apply about the alleged victim(s):*
	Victim(s) attends the above-named school.    Victim(s) attends another school.

	Witnesses

14.	Complete this section with the names of any potential witnesses.*
	Student Names:   Staff Names:   Parent Names:   Other Names (specify title of position for each):

	School Principal/Designee and Superintendent Section

	To be Completed by School Principal/Designee and Superintendent Note: The completed form must be kept on file in the school. The principal must promptly submit a copy of this form to the superintendent.

	Utilization of Preliminary Determination Provision

	If the school district’s policy permits the use of a preliminary determination for reports of HIB, question 1 and 2 below must be completed on every form. School districts who do not permit the use of a preliminary determination for reports of HIB, should leave this section blank.

	Question for the School Principal/Designee

School Principal/Designee and Superintendent Section To be Completed by School Principal/Designee and Superintendent Note: The completed form must be kept on file in the school. The principal must promptly submit a copy of this form to the superintendent. Utilization of Preliminary Determination Provision If the school district’s policy permits the use of a preliminary determination for reports of HIB, questions 1 and 2 below must be completed on every form. School districts that do not permit the use of a preliminary determination for reports of HIB, should leave this section blank. Question for the School Principal/Designee 1. Was a preliminary determination made not to initiate a HIB investigation because the reported incident or complaint is a report outside the scope of the definition of HIB? Yes No Question for the Superintendent 2. If the answer to question 1 is yes, will you require the school principal/designee to initiate a HIB investigation based on the scope of the definition of HIB? Yes No Incident Tracking If your school district utilizes a tracking system to track alleged incidents of HIB, insert the incident number. Incident number:___________________