Frenchtown Elementary School - Harassment, Intimidation, and Bullying Incident Report Form
This form must be submitted to the Principal within two (2) school days of the verbal incident report.
Name of Reporting Person (optional)
*No disciplinary action will be taken against an alleged aggressor based solely on an anonymous report.
Your title/position *
Did you file a verbal report with the Principal (or designee) on the same day of witnessing or receiving reliable information regarding the incident? *
If yes, date of verbal report
Under New Jersey law, "harassment, intimidation, or bullying" means any gesture, any written, verbal or physical act or any electronic communication, whether it is a single incident or a series of incidents, that is:
a.) Reasonably perceived as being motivated by either 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
b.) By any other distinguishing characteristic; and that
c.) 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. 18A:37-15.3, that substantially disrupts or interferes with the orderly operation of the school or the rights of other pupils; and that
d.) A reasonable person should know under the circumstances 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;
e.) Has the effect of insulting or demeaning any pupil or group of pupils; or
f.) Creates a hostile educational environment for the pupil by interfering with a pupil's education or by severely or pervasively causing physical or emotional harm to the pupil.
Name of targeted student *
Names(s) of alleged offender(s) *
Date(s) of Incident(s) *
Time of incident *
Where did the incident happen? *
Please describe the incident *
Please check the box(es) that best describes what the alleged offender did. *
Please choose all that apply.
Name(s) of witness(es) who have knowledge of this incident *
I certify that the information contained in this report is accurate and true to the best of my knowledge. *
Never submit passwords through Google Forms.
This form was created inside of Delaware Valley Regional High School. Report Abuse