Harassment, Intimidation, or Bullying (HIB) Reporting Form 338

	SCHOOL INFORMATION

	School District- Mahwah Township Public Schools

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

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

	INDIVIDUAL COMPLETING THE FORM

3.	If you prefer to remain anonymous, leave this section blank. Name of individual completing this form:

4.	Phone Number

5.	Email Address

	INCIDENT INFORMATION

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

7.	Approximate time of incident:*

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

9.	Location of alleged HIB incident*
	--Please Select--School propertySchool sponsored eventSchool busOff school groundsOnline via social media

10.	Alleged Offender(s)-Name(s) of alleged offender(s):*

11.	Based on your knowledge, select all that apply about the alleged offender(s): * Select at least 0 and no more than 0.
	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.

12.	Alleged Victim(s)-Name(s) of alleged victim(s)*

13.	Based on your knowledge, select all that apply about the alleged victim(s): * Select at least 0 and no more than 0.
	Victim(s) attends the above-named school.    Victim(s) attends another school.

14.	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.*

School Principal/Designee and Superintendent Section To be Completed by School Principal/Designee and Superintendent Note: The completed form must be kept on file in the school. The principal must promptly submit a copy of this form to the superintendent. Utilization of Preliminary Determination Provision If the school district’s policy permits the use of a preliminary determination for reports of HIB, question 1 and 2 below must be completed on every form. School districts who do not permit the use of a preliminary determination for reports of HIB, should leave this section blank. Question for the School Principal/Designee 1. Was a preliminary determination made not to initiate an HIB investigation because the reported incident or complaint is a report outside the scope of the definition of HIB? Yes No Question for the Superintendent 2. If the answer to question 1 is yes, will you require the school principal/designee to initiate an HIB investigation based on the scope of the definition of HIB? Yes No Incident Tracking If your school district utilizes a tracking system to track alleged incidents of HIB, insert the incident number. Incident number:___________________