HIB Incident Form ForLEAs

Date and Time Received

Date

Incident # (optional)

All allegations of HIB must be reported in writing and submitted to the principal within two school days from when a school employee or contracted service provider, witnesses or receives reliable information, that a student has been subject to HIB. A written statement from the alleged victim or other evidence may be attached to the back of this HIB 338 Form (e.g., screenshot, text thread, etc.)

The use of this form for reporting incidences of HIB is required.
This form shall be completed even if a preliminary determination is made under the LEA’s policy that the reported incident or complaint is a report outside the scope of the definition of HIB.
Required investigative procedures shall continue after the submission of this form to the school principal.
Principals are required to inform parents of all students involved in the alleged incident and keep a written record of the date, time, and manner of notification to parents.
The completed form must be kept on file in the school.
The principal must promptly submit a copy of this form to the superintendent.

The use of this form for reporting incidences of HIB is required.

Complete the form below to provide detailed information of the alleged HIB incident. If fields are not applicable or if the completing party is uncertain of the response, those fields may be left blank.

School District*

Begen Campus*

Passaic Campus*

Paterson Campus*

Hudson Campus*

Name of individual completing this form*

Role of individual completing the form e.g., teacher, lunchroom monitor, school bus driver, etc*

Phone number*

Email address*

example@example.com

Incident date (mm/dd/yyyy)*

Date

Approximate time of the incident*

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?)*

Specific incident locations e.g., on the morning school bus, in the science wing hallway, online via social media, etc*

Name(s) of alleged offender(s)

Based on your knowledge, select all that apply about the alleged offender(s)

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.

Name(s) of alleged victim(s)

Based on your knowledge, select all that apply about the alleged victim(s)

Victim(s) attends the above-named school.Victim(s) attends another school.

Complete this section with the names of any potential witnesses.

Student Names

Staff Names

Parent Names

Other Names (specify title or position for each)

Select the statements that best describes the alleged bullying behavior Check all that apply

Verbal e.g., teasing, name calling, derogatory comments, etcEmotional e.g., group exclusion, spreading rumors, taking belongings, etcPhysical e.g., hitting, pushing, inappropriate touching, etcElectronic e.g., attacking through social media, cyberbullying, offensive messaging, etc

Signature of Person Completing this HIB 338 Form

Date

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? Check one below and submit this form to the Superintendent.

Yes - Follow your school district’s policies for other reports (e.g., code of student conduct, referral to counseling services, etc).No- Refer to your school district’s HIB policy for initiating an HIB investigation.

Comments (Optional)

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? Check one and proceed as directed.

Yes- Notify the principal of this determination in writing and direct the principal to initiate an HIB investigation per the district’s policy.No- Follow your school district’s policies for other reports e.g., code of student conduct, referral to

Comments (Optional)

Directions

School Information

Individual Completing Form

Incident Information

Alleged Offender(s)

Alleged Victim(s)

Witnesses

Alleged Bullying Behavior(s)

Signature

School Principal/Designee and Superintendent Section

Utilization of Preliminary Determination Provision

1. Question for the School Principal/Designee

Questions for the Superintendent