Anonymous HIB Reporting

1.	Today's date*
	mm/dd/yyyy

2.	Alleged Target(s)*

3.	Alleged Actor(s) of HIB behavior*

4.	Date of Alleged Incident (mm/dd/yyyy)*
	mm/dd/yyyy

5.	School*
	--Please Select--Mahwah High SchoolRamapo Ridge Middle SchoolJoyce Kilmer SchoolLenape Meadows SchoolGeorge Washington SchoolBetsy Ross School

6.	Select the alleged category of Harassment, Intimidation, and Bullying*
	Race    Color    Religion    Ancestory    Origin    Gender    Sexual Orientation    Gender Identity & Expression    Mental, physical, or sensory disability    Other distinguishing characteristic

7.	Describe the nature of alleged harassment, intimidation, or bullying. Include and gesture, any relevant written, verbal, or physical act(s), or any electronic communication.*

8.	Location of alleged HIB incident*
	--Please Select--School propertySchool sponsored eventSchool busOff school grounds

9.	Witnesses: List below any person who you know or have reason to believe may have relevant information and indicate if the witness is a student, parent, staff member, or other.*