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:
- 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.
Student(s)/Person(s) Accused of Exhibiting Harassment, Intimidation or Bullying (HIB) Behavior:
- _______________________ 2. ________________________ 3. ____________________________ 4. _______________________ 5. ____________________
6. ______________________________
Student(s) Alleged to be the Target of HIB Behavior:
- ________________________ 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:
_______________________________________________________________________________________________________________
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_______________________________________________________________________________________________________________
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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)
