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
Person reporting the incident:
If other, please explain
Your Email Address
Your Phone Number
Name(s) of Alleged Victim(s)
Name(s) of Alleged Offender(s)
School Personnel that have been contacted (if any)
Date and Time of the Incident
Where did the incident occur?
Please Check all that apply.
All Purpose Room
School Grounds (outdoors)
On the way to/from school
During a school activity
Off school property
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.
How did you learn of the incident?
Why do you believe the incident occurred?
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.
Gender Identity & Expression
Mental, Physical or Sensory Disability
List the names of any witnesses or anyone that may have relevant information. Please indicate the relationship of the witness to the alleged victim.
Did a physical or emotional injury result from this incident? If yes, please describe.
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.
Please provide any other pertinent information that will assist in the investigation of this report.
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?
Before submitting, you may wish to print a hard copy for yourself, by using your browser's print function (Ctrl-P or Cmd-P).
Hit *Submit* below, and check that you **do not get any error messages after submit**. If there are no errors, you will see a confirmation message stating that the HIB report has been submitted.
**You will see an error message if you have missed a required question.
Never submit passwords through Google Forms.
This form was created inside of Westville School District.