HARASSMENT, INTIMIDATION, OR BULLYING INCIDENT REPORTING FORM
This form is to be confidentially maintained in accordance with the Family Educational Rights and Privacy Act, 20 U.S.C. § 1232g.

Directions: Bullying, harassment, or intimidation are serious and will not be tolerated. This is a form to report alleged bullying, harassment, or intimidation that occurred on school property; at a school-sponsored activity or event off school property; on a school bus; or on the way to and/or from school*, in the current school year. If you are a student victim, the parent/guardian of a student victim, a close adult relative of a student victim, or a school staff member and wish to report an incident of alleged bullying, harassment or intimidation, complete this form and return it to the Principal at the student victim’s school. Contact the school for additional information or assistance at any time.

“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:

1. 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; and

2. 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; and

3. Substantially disrupts or interferes with the orderly operation of the school or the rights of other students; and that

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

b. Has the effect of insulting or demeaning any student or group of students; or

c. Creates a hostile educational environment for the student by interfering with a student’s education or by severely or pervasively causing physical or emotional harm to the student.

Schools are required to address harassment, intimidation, and bullying occurring off school grounds, when there is a nexus between the harassment, intimidation, and bullying and the school (e.g., the harassment, intimidation, or bullying substantially disrupts or interferes with the orderly operation of the school or the rights of other students).
Name of Person Reporting the Incident
Optional
Your answer
Person reporting the incident: *
If other, please explain
Your Email Address
Optional
Your answer
Your Phone Number
Optional
Your answer
Name(s) of Alleged Victim(s) *
Your answer
Name(s) of Alleged Offender(s) *
Your answer
School Personnel that have been contacted (if any) *
Date and Time of the Incident *
Your answer
Where did the incident occur? *
Please Check all that apply.
Required
Describe the nature of the alleged harassment, intimidation or bullying. Include the names of people involved, what occurred and what each person said and did. Include specific words used. *
Your answer
How did you learn of the incident? *
Your answer
Why do you believe the incident occurred? *
Your answer
I believe the discrimination was based on: *
Note any distinguishing characteristics you feel were targeted, as defined by the Harassment, Intimidation and Bullying definitions provided above.
Required
List the names of any witnesses or anyone that may have relevant information. Please indicate the relationship of the witness to the alleged victim.
Your answer
Did a physical or emotional injury result from this incident? If yes, please describe. *
Your answer
Was the alleged victim absent from school as a result of the incident? If yes, please indicate the number of days and specific reason for the absence. *
Your answer
Please provide any other pertinent information that will assist in the investigation of this report.
Your answer
Did you file a verbal report with the Principal or designee on the same day of witnessing or receiving reliable information regarding behavior being reported? *
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