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High School Harassment, Intimidation and Bullying Reporting Form
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High School Harassment, Intimidation and Bullying Reporting Form

General Statement of Policy Prohibiting Religious, Racial or Sexual Harassment

Lower Cape May Regional School District maintains a firm policy prohibiting all forms of Harassment, Intimidation and Bullying.   All persons are to be treated with respect and dignity.  Any type of harassment, intimidation, or bullying by any pupil, teacher, administrator or other school personnel, which creates an intimidating, hostile or offensive environment, will not be tolerated under any circumstances.

1) Home Address
2) Work Address
3) Home Phone
4) Work Phone
5) Date of Alleged Incident(s) - If there were multiple incidents, please seperate each date with a coma
6) Type of HIB:
7) Name of person you believe harassed or was violent toward you or another person
8) If the alleged harassment or violence was toward another person, identify that person
9) Describe the incident(s) as clearly as possible, including such things as; where it occurred what force, if any, was used, any verbal statements (i.e. threats, requests, demands, etc); what, if any physical contact was involved, etc. (attach additional pages if necessary)
10) List any witnesses who were present (grade level if they attend school)
11) This complaint is filed based on my honest belief that the person below has harassed or has been violent to me or to another person. I hereby certify that the information I have provided in this complaint is true, correct and complete to the best of my knowledge and belief. (Type Name Below)
12) If you wish this report to be anonymous please remove your name from the complainant box above and in number 11. By doing this you will forfeit your rights to be informed of actions taken regarding the incident.
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