Harassment, Intimidation, or bullying
Incident Reporting Form

Person reporting the incident:


Staff Member





Name of Person Reporting the Incident:       Click the button to remain anonymous.

Your Email Address:

Your Phone Number:

Name of Person targeted in the Incident:

Name(s) of alleged offenders if known:

School Personnel that have been contacted (if any):       Click the button if incident has NOT been reported.

On what date(s) did the incident(s) occur:

Please enter a date.

Please enter a date.

Please enter a date.

Please enter a date.


Under New Jersey law, “harassment, intimidation, or bullying” means any gesture, any written, verbal or physical act or any electroniccommunication, 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.

Where did the incident occur? Please Check all that apply.

Classroom Hallway Restroom Locker Room Cafeteria Sports Field Parking Lot
School Bus Internet Cell Phone On the way to/from school During a school activity Off school property


Please check the box(es) that best describe what the alleged offenders did. Please choose all that apply.

Hitting Kicking Shoving
Spitting Hair Pulling Throwing
Teasing Name Calling Critical Remarks
Threats in Person Threats by Phone Threats by Email/Web
Insighting Fear Demanding Money Exploiting
Insulting/Demeaning Comments Intimidating Conduct Destruction of property
Stalking another Pupil Public Humiliation of Pupil Stealing or Theft
Cyber Bullying - Calling Cyber Bullying - Texting Cyber Bullying - Emailing
Cyber Bullying - Blog Cyber Bullying - Myspace Cyber Bullying - Facebook

Getting another person to hit or harm the student
Putting the student down and making the student a target of jokes
Making rude and/or threatening gestures
Excluding or rejecting the student
Spreading harmful rumors or gossip
Other (please describe):

Why do you think the harassment, intimidation or bullying occurred?

This discrimination was based on:

Race/Color/National Origin Age Sex
Disability Religion Other (if other describe below)

If Other:

Were there any witnesses? Yes     No

If yes, please provide their names:

Did a physical or emotional injury result from this incident? Yes     No

If yes, please describe:

Was the targeted individual absent from school as a result of the incident? Yes     No

If yes, please describe:

Do you have any additional information about this incident?

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