Andover Regional School District Incident Reporting Form
The Andover Regional School District is committed to providing a safe environment to all members of our community. Despite our best intentions, incidents between students do occur at times. If you wish to report a possible Harassment, Intimidation and Bullying (HIB) incident, please complete this form and immediately notify the Principal and/or the Anti-bullying Specialist. Contact the school for additional information or assistance at any time.
Name of Person Reporting Incident
Your answer
Date of Incident: *
Your answer
Location of Incident: *
Your answer
Name of targeted student: *
Your answer
Home School of Targeted Student *
Name(s) of alleged aggressor(s) (if known): *
Your answer
Name(s) of witness(es) (if known): *
Your answer
Please select the statement(s) that best describes the behavior being reported: *
Required
“Harassment, intimidation, or bullying” means any gesture, any written, verbal or physical act, or any electronic communication, as defined in N.J.S.A. 18A:37-14, whether it be a single incident or a series of incidents that: Is 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 by any other distinguishing characteristic- *******************************************************************************Please identify the actual or perceived characteristic below: *
Your answer
“Harassment, intimidation, or bullying” means any gesture, any written, verbal or physical act, or any electronic communication, as defined in N.J.S.A. 18A:37-14, whether it be a single incident or a series of incidents 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. 18A:37-15.3 ********************************************************************************Please identify the location of the alleged HIB: *
Your answer
“Harassment, intimidation, or bullying” means any gesture, any written, verbal or physical act, or any electronic communication, as defined in N.J.S.A. 18A:37-14, whether it be a single incident or a series of incidents that: Substantially disrupts or interferes with the orderly operation of the school or the rights of other students *******************************************************************************Please explain how this situation substantially disrupted or interfered with the orderly operation of the school or the rights of other students: *
Your answer
I understand that any student who knowingly makes a false accusation of an incident, HIB allegation or retaliation will be subject to disciplinary action including, but not limited to parent conferences, reprimand, detention, loss of privileges, and/or suspension. If the false accusations have civil and/or criminal elements then further actions may be taken by appropriate law enforcement agencies. *
Please provide additional details of the incident (be specific):
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