Salem High School Harassment, Intimidation & Bullying Form (H.I.B.)
HIB Defined - When trying to determine if an incident is HIB, compare it against the definition.

Does the incident meet all of the following?

 
-  Harassment, Intimidation, or bullying means any gesture, any written, verbal or physical act, or any electronic communications, whether it be a single incident or a series of incidents that:

 
-  ... is reasonably perceived as being motivated by any actual or perceived characteristic, such as race, color, religion, ancestry, national origin, gender, sexual orientation, gender identity and expression, or a mental, physical, or sensory disability; or by any other distinguishing characteristic; and that takes place on school property, at any school sponsored function, on a school bus, or off school grounds, as provided for in N.J.S.A. 37-15.3, that substantially disrupts or interferes with the orderly operation of the school or the rights of other students

 
-  ... takes place on school property, at any school sponsored function, or off school grounds

 
-  ... substantially disrupts or interferes with the orderly operation of the school or the rights of other students
And, does it meet one of these?

 
-  A reasonable person should know, under the circumstances, that the act(s) will have the effect of physically or emotionally harming a pupil or damaging the pupil's property, or placing a pupil in reasonable fear of physical or emotional harm to his/her person or damage to his/her property

 
-  Has the effect of insulting or demeaning any student or group of students

 
-  Creates a hostile educational environment for the pupil by interfering with a pupil's education or by severly or pervasively causing physical or emotional harm to the student


*The school district takes all offenses very seriously. In good faith we are to believe that all reported matters are the absolute truth and answered to the best of your knowledge.


This form is intended for parents, teachers, and students to report any incident of harassment, intimidation, or bullying. All Salem City School District staff members are required to enter their name and fill out ALL boxes. Everyone else can remain anonymous. However, if you want to be contacted for follow-up you will need to enter your contact information.

PLEASE NOTE: This form is being submitted to an electronic queue for investigation. There is no guarantee that it will be read immediately. In the event that a student is in imminent danger, please contact the school or your local police department immediately.

General Information
Date of Incident: *
MM
/
DD
/
YYYY
Time of Incident: *
Time
:
School: *
Indicate how you learned that a student may have been a victim of harassment, intimidation, or bullying. *
Required
Target (Victim) Information
First Name: *
Last Name: *
Gender: *
Grade *
Alleged Perpetrator(s)
Use the spaces provided to list the full legal name of the perpetrator or perpetrators in this incident.
*
Contact Information
First Name *
Last Name: *
Email Address: *
Phone Number: *
Best time to call: *
Classification
Please select all that apply in each category.
Verbal *
Required
Emotional *
Required
Physical *
Required
Electronic *
Required
Location of Incident
Where did the incident happen? *
(Choose all that apply)
Required
Witness Information
First Name: *
Last Name: *
Additional Witness Names *
Physical Evidence *
Required
Motivation
If you feel that the incident was in any way motivated by any of the following please indicate by checking where appropriate.
Additional Information
Is there any additional relevant information that you would like to provide?
Electronic Signature
Please place your initials in the box below to complete and press submit to complete the form. *
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