Do you know of a student experiencing harassment, intimidation, and/or bullying?

Wa He Lut Indian School has a zero tolerance HIB policy. Please let us know by filling out this form and add as much detail as you are able. You may leave your name and contact information blank to submit anonymously.

Your Name

Phone

Targeted Student*

Name(s) of Offenders*

On what date did the incident(s) occur? If exact date is unknown, give a timeframe.*

Where did the incident(s) occur? Check all that apply.*

Bus

Cafeteria/Gym

Classroom

Field Trip or School Activity (off-campus)

Hallway

Internet/Social Media

Parking Lot

Playground or Field

Restroom

School Common Area

Text or Phone Call

Other

Describe the incident(s). Check all that apply.*

Cyberbullying - occurred through phone, text, email, social media, etc

Excluding or rejecting the student (intentionally)

Getting another person to hit or physically harm the student

Hitting, kicking, shoving, spitting, hair pulling, or throwing an object at the student

Making rude or threatening gestures

Making the student fearful, demanding money or otherwise exploiting the student

Putting the student down or making them the target of jokes

Spreading harmful rumors or gossip

Teasing, name calling, making critical remarks or threatening the student in any way

Other

This space is provided if you chose OTHER or would like to add more detail about the incidents.

Why do you believe the incident(s) occurred?

Check any that apply. You will provide details in the next box.

You have spoken to anyone on staff about the incident(s) - provide names below

Witnesses? - provide names below

Physical injury as a result from the incident(s) - describe the injury below

Targeted student missed school as a result of the incident(s) - provide dates and reasons below

Provide names or details for any box checked above. Finally, is there any additional information you wish to provide?

Contact

Community Request

Records Request

Staff

Mental Health Services

WA HE LUT Indian School Agency is an equal opportunity employer and does not discriminate...

bottom of page