Remedial Action(s) Taken:________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
If Bullying Verified, Has Notification Been Made to Parents of Students Involved?
Parents’ Names: _____________________________
Parents’ Names: _____________________________
Parents’ Names: _____________________________
Parents’ Names: _____________________________
Date Sent:______________
Date Sent:______________
Date Sent:______________
Date Sent: ______________
If Bullying Verified, Have Invitation to Meetings Been Sent to Parents of Students Involved?
Parents’ Names: _____________________________
Parents’ Names: _____________________________
Parents’ Names: _____________________________
Parents’ Names: _____________________________
Date Sent:______________
Date Sent:______________
Date Sent:______________
Date Sent: ______________
Date of Meetings:
_______________________________
_______________________________
If Bullying Verified, Has School Developed Student Safety Support/Intervention Plan?
Y
N
(Attach bullying complaint and witness statements. If bullying is verified, attach notification to
parents of students involved, invitations to parent meetings, and records of parent meetings).
Adopted: January 24, 2012
Revised: March 27, 2012
Revised: May 12, 2015
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