Upper Township School District 525 Perry Road, Petersburg, NJ 08270 (609) 628-3500 HARASSMENT, INTIMIDATION OR BULLYING (HIB) Reporting Packet The following packet must be utilized whenever any allegations of HIB incidents have been observed. When there is sufficient evidence to warrant an investigation, it is mandatory that this packet be completed as a record of that investigation. Who reports HIB: Anyone who witnesses, hears or has knowledge of a HIB incident. To whom do you report HIB: Building principal, any administrator or any Anti-Bullying Specialist. District Anti-Bullying Coordinator:
Vanessa Strassner
Middle School Principal: Middle School Anti-Bullying Specialist:
Jeff Leek Tracey LeFever
Elementary School Principal: Andrea Urbano Elementary School Anti-Bullying Specialist: Suzi Pashuck Primary School Principal: Anti-Bullying Specialist:
Jamie Gillespie Kathy Weatherby
The definition of HIB as indicated in the Anti-Bullying Bill of Rights is as follows: HIB means any intentional gesture, any written, verbal or physical act, or any electronic communication, whether it be a single incident or series of incidents, that: • Is reasonably perceived as being motivated by 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 that; • Takes place on school property, at any school-sponsored function, or off school grounds as provided in section 16 of P.L. 2010, c 122 that; • Substantially disrupts or interferes with the orderly operation of the school or the rights of other students, that; • A reasonable person should know, under the circumstances, will have the effect of physically or emotionally harming a student or damaging the student’s property, or placing a student in reasonable fear of physical or emotional harm to his person or damage to his property or; • Has the effect of insulting or demeaning any student or group of students or; • Creates a hostile educational environment for the student by interfering with student’s education or by severely or pervasively causing physical or emotional harm to the student.
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Part 1: Reporting of a HIB Incident A. Verbal report of HIB Incident to Principal, Administrator or Anti-Bullying Specialist Person reporting:
____________________________________________
Date and Time:
____________________________________________
Report given to:
____________________________________________
Signature of Receipt:
____________________________________________
B. Principal notifies parents of involved students (Principal Use Only) Target’s parent/guardian:
____________________
Date:________________ Time: ________
Target’s parent/guardian:
____________________
Date: _______________ Time: ________
Target’s parent/guardian:
____________________
Date: _______________ Time: ________
Aggressor’s parent/guardian: ____________________
Date: _______________ Time: ________
Aggressor’s parent/guardian: ____________________
Date:________________ Time: ________
Aggressor’s parent/guardian: ____________________
Date: _______________ Time: ________
C. Written report of HIB Incident to be submitted to Building Principal within 2 school days of verbal report. Today’s Date: __________
Target Student Attends:
£ UTMS
£ UTES
£ UTPS
1) Name of Reporter/Person Filing the Report: _________________________________________________ (Reports may be made anonymously, but no disciplinary action will be taken against the aggressor solely on the basis of an anonymous report)
Phone Number: ____________________
Email: __________________________________________
2) Check whether you are the:
£ Target of the Behavior £ Reporter (not the target)
3) Check whether you are:
£ £ £ £ £
Administrator Parent Staff Member (Role and School)_______________________________ Student Other (specify): _______________
4) Information about the Incident(s): Name of Target: _________________________________________ Grade:
_____________________
Name(s) of Aggressor(s): __________________________________ Grade:
_____________________
Date(s) of Incident(s): ____________________________________ Time(s) of Day: _______________ Location(s) of Incident(s) (be specific): ____________________________________________________
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5) Witnesses (List people who saw the incident or have information about it): Name: ________________________
£ Student
£ Staff
£ Other: __________________
Name: ________________________
£ Student
£ Staff
£ Other: __________________
Name: ________________________
£ Student
£ Staff
£ Other: __________________
6) Incident(s) Description: Place an X next to each and all areas below that best describe what happened and use the space below these to provide further details if necessary including the specific actions of the parties with names of who did and said what: £ Any harassment, intimidation, or bullying involving physical aggression £ Spreading harmful rumors gossip £ Getting another person to hit or harm the student £ Making rude or threatening gestures £ Teasing, name-calling, criticizing, or threatening in person or by other means £ Demeaning/making victim of jokes £ Intimidating, (bullying), extorting, or exploiting £ Excluding or rejecting the target £ Electronic Communication (specify) ___________________________________________________ £ Other (specify) _____________________________________________________________________ Please provide further detail below: _______________________________________________________________________________________ ______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
7) Signature of Person Filing this Report: ____________________________Date: ________ Time: ______ (Reports may be filed anonymously) 8) Receiving Principal or Designee Signature: ________________________ Date: _______ Time: ______
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PART 2: INVESTIGATION OF THE INCIDENT: (Anti-Bullying Specialist Use Only) 1) Investigator(s): ________________________________________ 2) Interviews: Interviewed Target:
Name: _____________________________
Date: ________
Interviewed Aggressor(s):
Name: _____________________________
Date: ________
Name: _____________________________
Date: ________
Name: _____________________________
Date: ________
Name: _____________________________
Date: ________
Name: _____________________________
Date: ________
Name: _____________________________
Date: ________
Interviewed Witness(es):
3) Any prior documented incidents by aggressor(s): £ No (Explain any YES selection)
£ Yes
£ Yes (with this target)
4) Summary of Investigation: _____________________________________________________________________________________ _____________________________________________________________________________________ 5) Finding of Harassment, Intimidation or Bullying and/or Retaliation: (check all that apply) £ No £ Yes (HIB) £ Yes (Retaliation) 6) Did a physical injury result from this incident? £ No £ Yes If yes, did the injury require medical attention? £ No £ Yes 7) Was the student absent from school as a result of the incident? £ No £ Yes If yes, how many days? __________ 8) Did a psychological injury result from this incident? (place an X next to one of the following) £ No £ Yes (no sought psychological services) £ Yes (psychological services sought) 9) Signature of Investigator: _____________________________ Date: __________
Time: __________
10) Submitted to Building-Level Principal: Signature of Receipt: ____________________________ Date: __________
Time: __________
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PART 3: Principal Report to HIB Coordinator and Superintendent (Principal Use Only) Corrective Actions Imposed: (choose all that apply) £ £ £ £ £ £ £ £ £ £
Admonishment Deprivation of privileges Specify: ________________________ Detention Type of: ________________________ In-School Suspension Number of Days:_________________ None, the incident did not warrant any corrective action None were required, false allegation Out-of-School Suspension Number of Days: _______ Referred to Law Enforcement Temporary removal from cite of incident Other ________________________________________________________
Remedial Measures - Personal: (choose all that apply) £ £ £ £ £ £ £
Alternative placement Counseling Type _______________________________________________ I&RS Referral Parent Conference Peer Support Group Restitution and/or Restoration Schedule Change
Remedial Measures - Environmental: (choose all that apply) £ £ £ £ £ £ £ £
Aide Support Disciplinary action for involved staff who contributed to the HIB incident Educational Presentations Increased supervision of pupil before and after school Involvement of Community-Based Organizations Involvement of School Resource Officer Professional Development for certified/non-certified staff Schedule Change
Please note any other pertinent information in the space below: Signature of Principal: ___________________________ Date: ______________ Time: _________ Copy of report sent to (Original copy should be retained by the investigator and destroyed after one year): District HIB Coordinator: ____________________________________ Vanessa Strassner
Date:___________
Superintendent: ____________________________________________ Vincent J. Palmieri, Jr.
Date: ___________
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PART 4: Superintendent Actions (Superintendent Use Only) _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
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