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

 
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  HIB 338 Reporting Form
   
  Please complete all sections of this form. It will be submitted to the building principal via e-mail. Please note that formal disciplinary action may not be taken solely on the basis of an anonymous report.
   
  NJDOE Seal
   
  School Information
   
  School District - Delaware Valley Regional High School District
   
1.
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  Select Date
mm/dd/yyyy
   
  Delaware Valley Regional High School
   

 
  Individual Completing Form
   
  If you prefer to remain anonymous, please leave this section blank.
   
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  Incident Information
   
6.
*
  Select Date
mm/dd/yyyy
   
7.
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9.
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  Alleged Offender(s)
   
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  Alleged Victim(s)
   
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  Witnesses
   
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  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
   
  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, questions 1 and 2 below must be completed on every form. School districts that 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 a 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 a 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:___________________
   
 
 
 
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