{"id":4250,"date":"2017-08-10T10:08:15","date_gmt":"2017-08-10T14:08:15","guid":{"rendered":"http:\/\/www.nhvweb.net\/vhs\/home\/?p=4250"},"modified":"2021-10-04T17:25:51","modified_gmt":"2021-10-04T21:25:51","slug":"hib-incident-reporting-form","status":"publish","type":"post","link":"https:\/\/www.nhvweb.net\/vhs\/home\/hib-incident-reporting-form\/","title":{"rendered":"HIB Incident Reporting Form"},"content":{"rendered":"

Link to PDF version of form:\u00a0VHS HIB Reporting Form<\/a><\/p>\n

VOORHEES HIGH SCHOOL<\/strong><\/span><\/p>\n

Person Reporting Incident:\u00a0 Name: \u00a0_______________________________ \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 School\/Location: ______________________<\/p>\n

___ Student ___ Staff Member ___ Parent\/Guardian ___Volunteer ___ Other: ____________________<\/p>\n

Date of alleged incident:_____________ \u00a0 \u00a0Where did the alleged incident occur? _______________________<\/p>\n

Under New Jersey law, \u201charassment, intimidation, or bullying\u201d 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:<\/p>\n

    \n
  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<\/li>\n
  2. By any other distinguishing characteristic; and that<\/li>\n
  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<\/li>\n
  4. A reasonable person should know under the circumstances will have the effect of physically or emotionally harming a pupil or damaging the pupil\u2019s property, or placing a pupil in reasonable fear of physical or emotional harm to his\/her person or damage to his\/her property; or<\/li>\n
  5. Has the effect of insulting or demeaning any pupil or group of pupils; or<\/li>\n
  6. Creates a hostile educational environment for the pupil by interfering with a pupil\u2019s education or by severely or pervasively causing physical or emotional harm to the pupil.<\/li>\n<\/ol>\n

    Student(s)\/Person(s) Accused of Exhibiting Harassment, Intimidation or Bullying (HIB) Behavior:<\/p>\n

      \n
    1. _______________________ 2.\u00a0 ________________________ 3. \u00a0____________________________ \u00a04. _______________________ 5. ____________________<\/li>\n<\/ol>\n

      6.\u00a0 ______________________________<\/p>\n

      Student(s) Alleged to be the Target of HIB Behavior:<\/p>\n

        \n
      1. ________________________ 2.\u00a0 _______________________\u00a0 3. ______________________________<\/li>\n<\/ol>\n

        a. Please place an \u201cx\u201d next to the statement(s) that best describes the behavior reported:<\/p>\n\n\n\n\n\n\n\n\n\n\n
        ___ physical aggression or contact to a pupil<\/td>\n___ destruction of property<\/td>\n<\/tr>\n
        ___ teasing or name-calling<\/td>\n___ stalking another pupil<\/td>\n<\/tr>\n
        ___ insulting or demeaning comments<\/td>\n___ publicly humiliating a pupil<\/td>\n<\/tr>\n
        ___ threatening comments, gestures or physical acts<\/td>\n___ stealing or theft<\/td>\n<\/tr>\n
        ___ intimidating conduct toward another pupil<\/td>\n___ defacing\/destroying property<\/td>\n<\/tr>\n
        ___ spreading harmful rumors or gossip about a pupil<\/td>\n___ excluding or rejecting a pupil<\/td>\n<\/tr>\n
        ___ getting another person to harm a pupil<\/td>\n___ extorting or exploiting a pupil<\/td>\n<\/tr>\n
        ___ harassment, intimidation or bullying through electronic communications<\/td>\n___ other, please specify:__________________________<\/p>\n

        ______________________________________________<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

        b. Please describe below the details of the incident you are reporting:<\/p>\n

        _______________________________________________________________________________________________________________<\/p>\n

        _______________________________________________________________________________________________________________<\/p>\n

        _______________________________________________________________________________________________________________<\/p>\n

        _______________________________________________________________________________________________________________<\/p>\n

        _______________________________________________________________________________________________________________<\/p>\n

        _______________________________________________________________________________________________________________<\/p>\n

        _______________________________________________________________________________________________________________<\/p>\n

        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:<\/p>\n\n\n\n\n\n\n\n\n
        <\/td>\nName<\/span><\/td>\nWork Location\/School\/Grade<\/span><\/td>\nWitnessed Incident(s)<\/span><\/td>\n<\/tr>\n
        1.<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
        2.<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
        3.<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
        4.<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n
        5.<\/td>\n<\/td>\n<\/td>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

        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 \u00a0___ No<\/p>\n

        I certify the information contained in this Report is accurate and true to the best of my knowledge.<\/p>\n

        Signature of Person Making Report _____________________________________<\/p>\n

        Position (staff member\/parent\/pupil,etc.) _________________________________ \u00a0 \u00a0 \u00a0 \u00a0 Date \u00a0___________<\/p>\n

        Name of Person Receiving Report \u00a0_________________________________<\/p>\n

        Title ______________________________ \u00a0 \u00a0 \u00a0 \u00a0Date ___________<\/p>\n

        Report #: _____________ \u00a0 (to be assigned by Principal or designee)<\/p>\n","protected":false},"excerpt":{"rendered":"

        Link to PDF version of form:\u00a0VHS HIB Reporting Form VOORHEES HIGH SCHOOL Person Reporting Incident:\u00a0 Name: \u00a0_______________________________ \u00a0\u00a0\u00a0\u00a0\u00a0\u00a0 School\/Location: ______________________ ___ Student ___ Staff Member ___ Parent\/Guardian ___Volunteer ___ Other: ____________________ Date of alleged incident:_____________ \u00a0 \u00a0Where did the alleged incident occur? _______________________ Under New Jersey law, \u201charassment, intimidation, or bullying\u201d means any gesture, any […]<\/p>\n","protected":false},"author":9,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_genesis_hide_title":false,"_genesis_hide_breadcrumbs":false,"_genesis_hide_singular_image":false,"_genesis_hide_footer_widgets":false,"_genesis_custom_body_class":"","_genesis_custom_post_class":"","_genesis_layout":"","_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[1],"tags":[],"class_list":{"0":"post-4250","1":"post","2":"type-post","3":"status-publish","4":"format-standard","6":"category-uncategorized","7":"entry","8":"override"},"jetpack_featured_media_url":"","jetpack_sharing_enabled":true,"publishpress_future_action":{"enabled":false,"date":"2026-04-26 06:46:24","action":"change-status","newStatus":"draft","terms":[],"taxonomy":"category","extraData":[]},"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"_links":{"self":[{"href":"https:\/\/www.nhvweb.net\/vhs\/home\/wp-json\/wp\/v2\/posts\/4250","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.nhvweb.net\/vhs\/home\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.nhvweb.net\/vhs\/home\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.nhvweb.net\/vhs\/home\/wp-json\/wp\/v2\/users\/9"}],"replies":[{"embeddable":true,"href":"https:\/\/www.nhvweb.net\/vhs\/home\/wp-json\/wp\/v2\/comments?post=4250"}],"version-history":[{"count":7,"href":"https:\/\/www.nhvweb.net\/vhs\/home\/wp-json\/wp\/v2\/posts\/4250\/revisions"}],"predecessor-version":[{"id":6695,"href":"https:\/\/www.nhvweb.net\/vhs\/home\/wp-json\/wp\/v2\/posts\/4250\/revisions\/6695"}],"wp:attachment":[{"href":"https:\/\/www.nhvweb.net\/vhs\/home\/wp-json\/wp\/v2\/media?parent=4250"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.nhvweb.net\/vhs\/home\/wp-json\/wp\/v2\/categories?post=4250"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.nhvweb.net\/vhs\/home\/wp-json\/wp\/v2\/tags?post=4250"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}