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.

Bullying, harassment, or intimidation 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 by an actual or a perceived personal characteristic including race, national origin, marital status, sex, sexual orientation, gender identity, religion, ancestry, physical attributes, socioeconomic status, familial status, or physical or mental ability or disability; or,

• threatening or seriously intimidating; and,

• occurs on school property, at a school activity or event, or on a school bus; or,

• substantially disrupts the orderly operation of a school.

*“Electronic communication” means a communication transmitted by means of an electronic device, including a telephone, cellular phone, computer, or pager.

Upon submission the following personnel will be immediately notified via email:
The Principal (District HIB coordinator or supervisor );
the social worker (district HIB coordinator or supervisor );
the student facilitator, and any other staff member selected at the end of this form.

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    HIB Definitions

    Under New Jersey law, “harassment, intimidation, or bullying” means any gesture, any written, verbal or physical act or any electroniccommunication, whether it is a single incident or a series of incidents, that 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 that 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 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 Has the effect of insulting or demeaning any pupil or group of pupils; or 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.
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    Pre-Submission Checks

    Before submitting, you may wish to print a hard copy using your browser's print function (Ctrl-P or Cmd-P). Then 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.
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