This form is intended for parents, teachers, and students to report any incident of harassment, intimidation, or bullying. All New Jersey School District staff members are required to enter their name and fill out ALL boxes. Everyone else can remain anonymous. However, if you want to be contacted for follow-up you will need to enter your contact information.


PLEASE NOTE: This form is being submitted to an electronic queue for investigation. There is no guarantee that it will be read immediately. In the event that a student is in imminent danger, please contact the school or your local police department immediately.

General
Date of Incident:
Time of Incident:
School:
Indicate how you learned that a student may have been a victim of harassment, intimidation or bullying:
Target (Victim)
First Name:
Last Name:
Gender:
Grade:
First Name:
Last Name:
Gender:
Grade:
First Name:
Last Name:
Gender:
Grade:
Alleged Offender(s)
First Name:
Last Name:
First Name:
Last Name:
First Name:
Last Name:
Contact Info
First Name:
Last Name:
Email:
Phone Number:
Best time to call:
Verbal
Emotional
Physical
Electronic
Where did the incident happen (choose all that apply)?

Witnesses
First Name:
Last Name:
Physical Evidence
If you feel that the incident was in any way motivated by any of the following please indicate by checking where appropriate
Is there any additional relevant information that you would like to provide?
Be sure to enter all known information before submitting.