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.
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.
Physical aggression or contact to a pupil
Teasing or name-calling
Insulting or demeaning comments
Threatening comments, gestures, or physical acts
Intimidating conduct towards another pupil
Spreading harmful rumors or gossip about a pupil
Getting another person to harm a pupil
Harassment, intimidation or bullying through electronic communication
Destruction of property
Stalking another pupil
Public humiliation of a pupil
Stealing or theft
Excluding or rejecting a pupil
Extorting or exploiting a pupil
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.
Click to validate this form
Never submit passwords through Google Forms.
This form was created inside of Delaware Valley Regional High School.