Harassment, Initimidation, Bullying Incident Reporting Form
Cicely L. Tyson Middle/High School
EAST ORANGE SCHOOL DISTRICT
DIVISION OF OPERATIONS, COMPLIANCE & EDUCATIONAL SUPPORT SERVICES
715 PARK AVENUE
EAST ORANGE, NJ 07017-1026
Please note: reports may be filed anonymously; however, no disciplinary consequences will be taken against an alleged aggresor(s) solely on the basis of an anonymous report.
Name of Person Reporting Incident
Your answer
Person making report is a:
* one choice only*
Date of Report:
Your answer
Date of Alleged Incident:
Your answer
Approximate Time of Incident:
Your answer
Person making report:
Required
Person making report:
*Was told by(indicate name and whether the person informing you was alleged victim, or witness, or told by another, etc.)*
Your answer
Name of student(s) alleged to be target of HIB
Your answer
Grade
Name(s) of Students(s)/person(s) accused of HIB
Your answer
Grade
Name(s) of any person(s) or student(s) you believe either witnessed or have knowledge of the incident you are reporting.
Your answer
School/Grade/Work Location
Your answer
Where did the incident occur?
*check all that apply*
Required
What best describes what happened?
*check all that apply*
Required
Did physical injury result from the incident?
*CHECK ONE ONLY*
Required
Was student absent from school as a result of the incident? Yes or No..if yes please explain.
Your answer
Identify what harm you believe was or may have been caused by the alleged incident.
*check all that apply*
Required
Describe the alleged HIB incident in detail below:
Your answer
Signature of person submitting form:
Your answer
Date:
Your answer
Signature of person receiving form:
Your answer
Date:
Your answer
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