Bordentown Regional School District (BRSD) - Harassment, Intimidation /Bullying (HIB) Confidential Reporting Form

Directions: Bullying, harassment, or intimidation (HIB) are serious and will not be tolerated. This form can be completed by the student who is the target of alleged HIB acts, the parent/guardian of the student, staff members, community members or other students who may witness the alleged HIB acts. 

HIB means intentional conduct, including verbal, physical, or written conduct or an intentional electronic communication that creates a hostile educational environment by substantially interfering with a student’s educational benefits, opportunities, or performance, or with a student’s physical or psychological well-being and is:

  • Motivated either by an actual or perceived characteristic, such as race, color, religion, ancestry, national origin, gender, sexual orientation, gender identity and expression, or a mental, psychical or sensory disability, or by any other distinguishing characteristic; and that 

  • Takes place on school property, at any school-sponsored function, on a school bus, or off school grounds that substantially disrupts or interferes with the orderly operation of the school or the rights of other students; and that

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

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

  • 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. 

(July 2022)
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Please list today's date in XX/XX/XXXX format: *
Please list the school where the HIB incident took place or is taking place.  If more than one school please click all that apply:   *
Please list the relationship that you have to the incident being described: *
Please give the full first and full last name of the student who is the target of the HIB acts? *
Please list the full name - if known - of the person or persons who are the alleged offenders(s) *
Please list the age, or ages, of the target and offender, if known, who are listed above.
Is the alleged offender, or offenders, a student, or students in the BRSD? *
Please list the date or dates of the incident that you are reporting in an XX/XX/XXXX format *
Where did the incident happen (choose all that apply)?

Place an X next to the statement(s) that best describes what happened (choose all that apply):

If you chose "Electronic communication" or "Other" to the previous question please specify the communication or the behavior here:
Please describe here what the alleged offender(s) said or did: *
Please indicate why the bullying, harassment or intimidation occurred: *
Did a physical injury result from this incident? *
If there was a physical injury, do you think there will be permanent effects?
Was the student who was the target absent from school as a result?
Do you believe that an emotional or psychological injury result from this incident?
Have any psychological services been sought following the incident?
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Is there any additional information you would like to provide? If you have nothing else to report please type "No" as this question requires a response.
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