Harassment, Intimidation, Bullying (Hib) Incident Report Form (Page 2 of 2) in pdf

Harassment, Intimidation, Bullying (Hib) Incident Report Form Page 2

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

Harassment, Intimidation, Bullying (Hib) Incident Report Form Page 2