2023-2024 Lakewood Public School District HIB Form 338 School Personnel/Contracted Service Provider

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2023-2024 HIB Form 338 - To be completed by School Personnel

All allegations of HIB must be reported in writing and submitted to the principal within two school days from when a school employee or contracted service provider, witnesses or receives reliable information, that a student has been subject to HIB.

The use of this form for reporting incidents of HIB is required by the NJDOE.

This form shall be completed even if a preliminary determination is made under the district's HIB policy that the reported incident or complaint is a report outside of the scope of the definition of HIB.

Required investigative procedures shall continue after the submission of this form by the School Principal.

The completed form must be maintained on file in the school district.

The Principal must promptly submit this form and a copy of his/her investigative findings to the Superintendent via HIBSTER.

Name of School student attends: *

LECC, Campus 1

LECC, Campus 2

LECC, Campus 3

Spruce Street School

Piner Elementary School

Clifton Avenue Grade School

Ella G. Clarke School

Oak Street School

Lakewood Middle School

Lakewood High School

Name of Individual completing this form. You must report your name as a Mandatory Reporter. *

Relation of individual completing this form (For example, teacher, lunchroom monitor, paraprofessional, school bus driver, etc.). As a mandatory reporter, you must identify your position

Phone Number. *

Email address. *

Date of Incident: *

YYYY

Approximate time of incident: *

Time

Describe the incident with as much detail as possible. What was the incident? Who was involved in the incident? How were you made aware of the incident? What happened at the time of the incident? How did the incident occur? *

Specific Incident Location (For example, on the morning school bus, in the science wing hallway, online via social media, etc.) *

Name of alleged offenders. *

Based on your knowledge, select all that apply about the alleged offenders: *

Alleged offender (s) attends the above-named school.

Alleged offender(s) attends another school.

Alleged offender (s) works for the school/school district.

Alleged offender (s) does not work for the school/school district.

None of the above.

Required

Name of the alleged victims. *

Based on your knowledge, select all that apply about the alleged victim (s): *

Victim (s) attends the same school.

Victim (s) attends another school.

None of the above

Required

School ID Number of alleged victims. *

Names of any potential student witnesses. *

Names of any potential staff witnesses. *

Names of any potential parent witnesses. *

Names of any other potential witnesses. *

Select the statement (s) that best describes the alleged bullying behavior: *

Verbal (For example, teasing, name calling, derogatory comments, etc.)

Emotional (For example, group exclusion, spreading rumors, taking belongings, etc.)

Physical (For example, hitting, pushing, inappropriate touching, etc.)

Electronic (For example, attacking through social media, cyberbullying, offensive messaging, etc.)

Required

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