Anonymous Harassment, Intimidation, & Bullying Report Form

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Anonymous Harassment, Intimidation, & Bullying Report Form - Fair Haven Public Schools

Any individual may submit a report of alleged harassment, intimidation, & bullying by submitting this form. You may remain anonymous in submitting this form, or you may leave your contact information if you wish to do so, however that is NOT required in order to submit an allegation of HIB. Please feel free to contact Knollwood or Sickles School if you have any questions or concerns.

This form may be submitted out of concern for any individual having potentially committed any acts of HIB against a student in our schools. This includes potential offenders who are current students of the Fair Haven schools, former students of the Fair Haven schools, students enrolled in school districts other than the Fair Haven Schools, or by employees of the Fair Haven schools.

Harassment, Intimidation, and Bullying (HIB) Definition:

(N.J.S.A. 18A:37-14) - N.J.S.A. 18A:37-15 (b) (2) and N.J.S.A. 18A: 37-15.3

"Harassment, Intimidation or Bullying" is defined as any gesture or written, verbal or physical act, or any electronic communication, whether it be a single incident or a series of incidents, that is reasonably perceived as being motivated either by an 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 handicap, or by any other distinguishing characteristic, but not limited to, that takes place on school property, at any school sponsored function, on a school bus, or off school grounds, as provided for in section 16 of P.L. 2010, c122 (C.18A:37-15.3), that substantially disrupts or interferes with the orderly operation of the school or the rights of other students and that:

a. 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 harm to his/her person or damage to his/her property; or

b. Has the effect of insulting or demeaning any pupil or group of pupils in such a way as to cause substantial disruption in, or substantial interference with, the orderly operation of the school; or

c. Creates a hostile education environment for the pupil by interfering with a pupil's education or by severely or pervasively causing physical or emotional harm to the pupil

Name of Alleged Offender(s) (If known)

You may list as many names as you feel are relevant.

If you are unsure of a full name, but know a first name and any additional identifying piece of information (e.g. John in 5th Grade), please feel free to share what you can to assist us in ensuring we are able to respond to your concern.

Name of Alleged Victim(s) *

You may list as many names as you feel are relevant.

Approximate date(s) of alleged harassment, intimidation, bullying: *

If unsure of exact dates, you may enter a general timeline that you feel is appropriate

Where did the incident(s) occur? *

Please check all that apply

At school during school hours

On school grounds after school hours

On a school bus

Outside of school and school hours

Digitally (potential cyber bullying?)

I am not exactly sure when and where it occurred

Other:

Required

Type of incident *

Please check all that apply

Verbal - (Name calling, taunting/ridiculing, mocking, offensive comments, teasing, demeaning comments, other verbal)

Emotional - (offensive graffiti, excluding from a group, spreading rumors, being forced to do something against the victim's will, taking possessions/money, other emotional)

Physical - (kicking, hitting/punching, pushing, pinching, stalking, inappropriate touching, gesture, other physical)

Electronic - (offensive text messages, offensive emails, sending of degrading images, posting rumors or lies about the victim(s), assuming a person's electronic identity with the intent of causing harm, other electronic)

Required

Description of incident(s) *

Please describe the incident(s) to the extent of your knowledge.

Are you aware of any potential witnesses to this allegation of HIB? *

If yes, please provide their names and whether you believe they are a parent, staff member, or are of student age.

If any of the witness(es) are of student age, please include whether you believe they are a student(s) of the Fair Haven schools or, if not, please indicate where they do go to school if you are aware so that we may investigate further.

Do you have any physical evidence of the incident(s)? *

Screenshots, hard copies, photos, videos, etc. - Please note that the district does not have a means by which to accept physical evidence anonymously. If you wish to share physical evidence, please enter your contact information in the final question of this form so that our Anti-Bullying Specialist may contact you to arrange receipt of any physical evidence and to determine if you prefer to remain anonymous to any other parties as a matter of the investigation.

Yes

Is there anything else you would like to share with regard to this incident?

NOT REQUIRED - but if you would like to provide your name and contact information to assist us in our follow up, you may do so below:

Reminder, if you have physical evidence that you wish to share, you will need to enter your contact information in the space below so that our school Anti-Bullying Specialist may arrange receipt of this evidence. At your request, the Anti-Bullying Specialist will respect and honor your anonymity with regard to all other parties involved in any subsequent investigation.

If you do not have, or do not wish to share, any physical evidence you do not need to enter any contact information below if you wish to remain anonymous.

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