Harassment, Intimidation, Bullying (Hib) Incident Report Form
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1
2Bridgewater-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
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