HIB Incident Form ForFamilies

To Be Completed by Families / Caregivers

This form should be used by parents or guardians to report allegations of 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.). Once the form is received by the school, the principal is responsible for implementing the school district’s policy and procedures. An investigation shall be completed as soon as possible, but not later than 10 school days from the date of the written report of the incident. Should you have any questions about the investigation, please contact the school principal.
Date and Time Received

MonthDayYear
Date
Incident # (optional)
Directions
Complete the form below to provide detailed information of the alleged HIB incident. If some fields are not applicable or if you are uncertain of the response, you may skip those fields. This form may be submitted anonymously.
School Information
School District
School - Bergen
School - Passaic
School - Paterson
School - Hudson
Individual Completing Form
If you prefer to remain anonymous, leave this section blank. Individuals filling out this HIB 338 Form as an anonymous reporter may consider adding their name as a witness.
Name of individual completing this form
Relation to individual involved in alleged incident of HIB (e.g., parent, guardian, grandparent, etc.):
Phone number
Email address
example@example.com
Incident Information
Incident date (mm/dd/yyyy)

MonthDayYear
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 location(s) (e.g., on the morning school bus, in the science wing hallway, online via social media, etc.)
Alleged Offender(s)
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.
Alleged Victim(s)
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.
Witnesses
Complete this section with the names of any potential witnesses.
Student Names
Staff Names
Parent Names
Other Names (specify title or position for each)
Signature
Signature of Person Completing this HIB 338 Form
Date

MonthDayYear
Date
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.
1. Question for the School Principal/DesigneeWas 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)
2. Questions for the SuperintendentIf 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 counseling services, etc.) and maintain a copy of this form.
Comments (Optional)
Should be Empty:

To Be Completed by Families / Caregivers

Directions

School Information

Individual Completing Form

Incident Information

Alleged Offender(s)

Alleged Victim(s)

Witnesses

Signature

School Principal/Designee and Superintendent Section

Utilization of Preliminary Determination Provision