Link to PDF version of form: VHS HIB Reporting Form

VOORHEES HIGH SCHOOL

Person Reporting Incident:  Name:  _______________________________        School/Location: ______________________

___ Student ___ Staff Member ___ Parent/Guardian ___Volunteer ___ Other: ____________________

Date of alleged incident:_____________    Where did the alleged incident occur? _______________________

Under New Jersey law, “harassment, intimidation, or bullying” means any gesture, any written, verbal or physical act or any electronic communication, whether it is a single incident or a series of incidents, that is:

1. 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
2. By any other distinguishing characteristic; and that
3. 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
4. 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
5. Has the effect of insulting or demeaning any pupil or group of pupils; or
6. 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.

Student(s)/Person(s) Accused of Exhibiting Harassment, Intimidation or Bullying (HIB) Behavior:

1. _______________________ 2.  ________________________ 3.  ____________________________  4. _______________________ 5. ____________________

6.  ______________________________

Student(s) Alleged to be the Target of HIB Behavior:

1. ________________________ 2.  _______________________  3. ______________________________

a. Please place an “x” next to the statement(s) that best describes the behavior reported:

___ physical aggression or contact to a pupil	___ destruction of property
___ teasing or name-calling	___ stalking another pupil
___ insulting or demeaning comments	___ publicly humiliating a pupil
___ threatening comments, gestures or physical acts	___ stealing or theft
___ intimidating conduct toward another pupil	___ defacing/destroying property
___ spreading harmful rumors or gossip about a pupil	___ excluding or rejecting a pupil
___ getting another person to harm a pupil	___ extorting or exploiting a pupil
___ harassment, intimidation or bullying through electronic communications	___ other, please specify:__________________________ ______________________________________________

b. Please describe below the details of the incident you are reporting:

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

c. Please list below the name(s) of any person(s) or pupil(s) you believe either witnessed or have knowledge of the incident you are reporting:

	Name	Work Location/School/Grade	Witnessed Incident(s)
1.
2.
3.
4.
5.

d. Did you file a verbal report with the Principal or designee on the same day of witnessing or receiving reliable information regarding behavior being reported? ___ Yes  ___ No

I certify the information contained in this Report is accurate and true to the best of my knowledge.

Signature of Person Making Report _____________________________________

Position (staff member/parent/pupil,etc.) _________________________________         Date  ___________

Name of Person Receiving Report  _________________________________

Title ______________________________        Date ___________

Report #: _____________   (to be assigned by Principal or designee)