Bullying (HIB) Reporting
Person Reporting incident:
Name of person reporting the incident:
If you wish to remain anonymous, leave this blank.
Your answer
Email Address of the person reporting the incident
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Your answer
Phone number of the person reporting the incident:
If you wish to remain anonymous, leave this blank.
Your answer
Name of the person TARGETED in this incident:
This field is required, please enter the name of the person the incident was directed towards.
Your answer
Name(s) of the alleged offenders, if known:
This field is required, please enter the name or names of the people allegedly involved in this incident.
Your answer
Have any school personnel been contacted about this incident?
If Yes, enter the name of the school personnel contacted:
Your answer
1) On what dates did the incident occur?
Please enter dates for each incident.
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2) On what dates did the incident occur?
Please enter dates for each incident.
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3) On what dates did the incident occur?
Please enter dates for each incident.
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4) On what dates did the incident occur?
Please enter dates for each incident.
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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:
1) 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

2) By any other distinguishing characteristic; and that

3) 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

4) 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; or

5) Has the effect of insulting or demeaning any pupil or group of pupils; or

6) 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.

Where did the incident occur? Please check all that apply.
Please enter a location/locations the incident(s) occurred.
Please check the box(es) that best describe what the alleged offender(s) did. Please choose all that apply.
Why do you think the harassment, intimidation, or bullying occurred?
Your answer
This discrimination was based on:
Where there any witnesses?
If yes, please include their names:
Your answer
Did a physical or emotional injury result from this incident?
If yes, please describe:
Your answer
Was the targeted individual absent from school as a result of the incident?
Do you have any additional information about this incident?
Your answer
Did you file a verbal report with the principal or designee on the same day of witnessing or receiving reliable information regarding the behavior being reported?
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