"Harassment, Intimidation, Bullying (Hib) Incident Report Form - Bridgewater-Raritan Regional School District"

ADVERTISEMENT
ADVERTISEMENT

Download "Harassment, Intimidation, Bullying (Hib) Incident Report Form - Bridgewater-Raritan Regional School District"

Download PDF

Fill PDF online

Rate (4.6 / 5) 14 votes
Bridgewater-Raritan Regional School District
Harassment, Intimidation, Bullying (HIB)
Incident Report Form
Date
Date of Report:
Enter Date.
allegation
Enter Date.
was reported:
Date of alleged
Enter Date.
School:
Choose school
HIB Incident:
Person
Date Report
Conducting HIB
Submitted to
Enter Date.
Investigation:
Principal
Alleged
Name:
Enter Name.
Grade:
Aggressor:
State ID #:
Enter Number.
Alleged Aggressor
Parent
Involved in Prior
Choose Yes or No.
Notification
Enter Date
HIB?
Date:
Name:
Enter Name.
Alleged Target:
Grade:
State ID #:
Enter Name.
Alleged Target
Parent
Involved in Prior
Choose Yes or No.
Notification
Enter Date.
HIB?
Date:
Location of alleged HIB Incident: (Mark with an “x” and complete all that apply)
School property
Identify:
School sponsored function
Identify:
School bus
Identify:
Off school grounds
Identify:
Time/Period:
Indicate how you learned of alleged HIB incident:
Witnessed Event
Informed by Alleged Victim
Informed by another person
Identify:
Check all actual or perceived characteristics that were or may have been motivational
factors in the alleged HIB incident:
☐ Race
☐ National Origin
☐ Gender, Identity and/or Expression
☐ Color
☐ Gender
☐ Mental Physical, or Sensory Disability
☐ Religion
☐ Ancestry
☐ Sexual Orientation
☐ Other (specify):
List below any person who you know or have reason to believe may have relevant
information and indicate if student, parent, staff or other.
☐ Student
☐ Staff
☐ Other
Name:
Click here to enter text.
☐ Student
☐ Staff
☐ Other
Name:
Click here to enter text.
☐ Student
☐ Staff
☐ Other
Name:
Click here to enter text.
CONFIDENTIAL
01/24/2017
Bridgewater-Raritan Regional School District
Harassment, Intimidation, Bullying (HIB)
Incident Report Form
Date
Date of Report:
Enter Date.
allegation
Enter Date.
was reported:
Date of alleged
Enter Date.
School:
Choose school
HIB Incident:
Person
Date Report
Conducting HIB
Submitted to
Enter Date.
Investigation:
Principal
Alleged
Name:
Enter Name.
Grade:
Aggressor:
State ID #:
Enter Number.
Alleged Aggressor
Parent
Involved in Prior
Choose Yes or No.
Notification
Enter Date
HIB?
Date:
Name:
Enter Name.
Alleged Target:
Grade:
State ID #:
Enter Name.
Alleged Target
Parent
Involved in Prior
Choose Yes or No.
Notification
Enter Date.
HIB?
Date:
Location of alleged HIB Incident: (Mark with an “x” and complete all that apply)
School property
Identify:
School sponsored function
Identify:
School bus
Identify:
Off school grounds
Identify:
Time/Period:
Indicate how you learned of alleged HIB incident:
Witnessed Event
Informed by Alleged Victim
Informed by another person
Identify:
Check all actual or perceived characteristics that were or may have been motivational
factors in the alleged HIB incident:
☐ Race
☐ National Origin
☐ Gender, Identity and/or Expression
☐ Color
☐ Gender
☐ Mental Physical, or Sensory Disability
☐ Religion
☐ Ancestry
☐ Sexual Orientation
☐ Other (specify):
List below any person who you know or have reason to believe may have relevant
information and indicate if student, parent, staff or other.
☐ Student
☐ Staff
☐ Other
Name:
Click here to enter text.
☐ Student
☐ Staff
☐ Other
Name:
Click here to enter text.
☐ Student
☐ Staff
☐ Other
Name:
Click here to enter text.
CONFIDENTIAL
01/24/2017
Bridgewater-Raritan Regional School District
Harassment, Intimidation, Bullying (HIB)
Incident Report Form
Describe nature of alleged HIB. Include any gesture, any written, verbal or physical act(s),
or any electronic communication (attach additional sheets if necessary).
Identify what harm you believe was or may have been caused by the alleged incident.
Check all that apply:
Substantial disruption or interference with the orderly operation of the school or the rights of
other pupils
Physical or emotional harm
Insulting or demeaning
Damaging property
Creates a hostile educational environment by interfering with pupil’s education
Describe in narrative form what harm you believe was caused to the student and the basis
for your belief.
Name:
Date:
In accordance with N.J.S.A. 18A:37-15
All acts of HIB shall be reported verbally to the school principal on the same day when
the individual witnessed or received reliable information regarding any such incident.
All acts of HIB shall be reported in writing to the school principal within two school
days of when the school employee witnessed or received reliable information
regarding any such incident.
In accordance with N.J.S.A. 18A:37-16
A member of a board of education or a school employee who promptly reports an
incident of HIB to the appropriate school official designated by the school district’s
policy or to any school administrator, and who makes this report in compliance with
the procedures in the district’s policy is immune from a cause of action for damages
arising from any failure to remedy the reported incident.
Staff Use Only:
Id#:
CONFIDENTIAL
01/24/2017
Page of 2