Nutley Public Schools

Harassment, Intimidation, Bullying (HIB)

Incident Report Form

Date of alleged HIB Incident: / School:
Date allegation was verbally reported:
Person who allegedly committed the HIB-related behavior: / Grade:
Recipient of the HIB-related behavior: / Grade:
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 / Color
Religion / Ancestry
National Origin / Gender
Sexual Orientation / Gender Identity and Expression
Mental, Physical, or Sensory Disability
Other Distinguishing Characteristic / Describe:
List below any person who you know or have reason to believe may have relevant information and indicate if student, parent, staff or other.
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#:

PLEASE RETURN THIS FORM TO THE

ANTI-BULLYING SPECIALIST

CONFIDENTIAL