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Cape May City School District

Reporting Form for Harassment, Intimidation and Bullying


1.   Name of person filing the report: ______________________________________________________

(Note: Reports may be made anonymously, but no disciplinary action will be taken against the aggressor solely on the basis of an anonymous report)


2.   Check whether you are:          ___ Student    ___Parent        ___Administrator        ___Other

___Staff member (specify role_________________________________

 

3.   Check whether you are the :   ___Target of the behavior       ___ Reporter (not the target)

 

4.   Your contact information/phone number(s)/email: _________________________________________

 

5.   Date of Alleged Incident:       ___________________          Time of Day: ______________________

 

6.   Name of Target(s) of behavior: ________________________________________Grade/Age (if available)___________

 

7.   Name(s) of Alleged Aggressor(s): ___________________________________________________________________________

 

8.   Check all actual or perceived characteristics that were or may have been motivational in the alleged bullying incident:

_____              Race

_____              Color

_____              Religion

_____              Ancestry

_____              National Origin

_____              Gender

_____              Sexual Orientation

_____              Gender Identity and Expression

_____              Mental or Physical or Sensory Disability

_____              OTHER actual or perceived characteristics (listed below)

__________________________________________________________________________________________


9.   Location of alleged HIB incident. Check all that apply and specify/describe location:

_____ School property _______________________________________________________________________

_____ School-sponsored function: _____________________________________________________________

_____ School bus: __________________________________________________________________________

_____ Off school grounds: ___________________________________________________________________


10.   Indicate how you learned that a student may have been the victim of harassment, intimidation or bullying:

_____Witnessed incident

_____ Informed by Alleged Victim

_____ Informed by other person (identify if student, parent, staff person, and list below or attach list)

________________________________       student           parent         staff          other (_______________)

________________________________       student           parent         staff          other (_______________)

________________________________       student           parent         staff          other (_______________)

________________________________       student           parent         staff          other (_______________)


11.   Was someone supervising when the incident occurred?

________________________________       student           parent         staff          other (_______________)

________________________________       student           parent         staff          other (_______________)

________________________________       student           parent         staff          other (_______________)

________________________________       student           parent         staff          other (_______________)


12.   Describe the nature of alleged harassment, intimidation or bullying. Include any gesture, any relevant written, verbal or physical act(s), or any electronic communication (attach additional sheets if necessary)

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________Additional sheets attached:                                                                    yes                no

13.   Identify what harm you believe was or may have been caused by the alleged incident. Check all that apply:

_____Substantial disruption or interference with orderly operation of school or rights of others

_____Physical or emotional harm

_____Insulting or demeaning

_____Creates a hostile educational environment

_____Other (list below)

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


14.   Incident 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 bullying, harassment or intimidation that involves physical aggression

___Getting another person to hit or harm a student

___Teasing, name-calling, criticizing, or threatening (in person or by other means)

___Intimidating

___Spreading harmful rumors or gossip

___Making rude or threatening gestures

___Demeaning/making victim of jokes

___Excluding or rejecting

___Electronic Communication (specify) ______________________________________


Please provide further details below:

 

 

 

 

 

Additional sheets attached:                  yes                     no


Signature of Person Filing this Report: _______________________________________Date: ______________


Disposition – Completed report forms should be given to the building Principal/Superintendent.