Harassment, Intimidation And Bullying (Hib) Incident Report Form
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1Greenwich Township School District,
101 Wyndham Farm Boulevard, Stewartsville, NJ 08886
Effective: 8/1/2016
Harassment, Intimidation and Bullying (HIB) Incident Report Form
Name(s) of Alleged Target:
Name(s) of Alleged Perpetrator:
School :
Date of Incident:
Time of Incident:
Please check all boxes below in which the actual or perceived characteristic was or may have been a motivational factor in the
alleged HIB incident.
Race
National Origin
Gender
Mental or Physical Disability
Color
Ancestry
Sexual Orientation
Gender Identity and Expression
Religion
Other Actual or Perceived Characteristic
:
(list characteristic)
How did you learn that a student may have been the target of HIB? Please check the appropriate box below.
Alleged Target
Witnessed Incident
Informed by Alleged Target
(self-report)
Informed by
:
(name of person(s)
Please list below any persons who you know or have reason to believe may have information regarding this matter. Please
identify if they are a student, staff member, parent, other. (Example: John Doe, teacher)
Please check the box below that identifies the location and time of the alleged HIB incident.
Location on School Property:
Name/Date of School Sponsored Event:
School Bus Incident Before School
School Bus Incident After School
School Bus Incident on Field Trip
Off School Grounds
:
(please explain)
Electronic Communication (cell phone, internet, digital media, etc.)
Please describe nature of alleged HIB. Include any gesture, relevant verbal, written or physical acts, or any electronic
communication.
I certify that the information contained in this report is accurate and true to the best of my knowledge.
Individuals, other than district personnel, may choose to submit this report anonymously. Please note, in accordance with the Anti-Bullying Bill of Rights Act, no
formal disciplinary action is permitted on the basis of anonymous reporting alone.
Name of Person Reporting:
Signature:
Date:
FOR DISTRICT USE ONLY
Name of Person Receiving Report:
Date Report Received:
Date Principal Received Verbal Report:
Date Principal Received Written Report:
Date Principal Initiated Investigation:
Report No.: 201617-
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