Bullying Verified?
Yes ___
No ____
Remedial Action(s) Taken:____________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
If Bullying Verified, Has Notification Been Made to Parents of Students Involved?
Parents’
Parents’
Parents’
Parents’
Names:
Names:
Names:
Names:
_____________________________ Date
_____________________________ Date
_____________________________ Date
_____________________________ Date
Sent:______________
Sent:______________
Sent:______________
Sent: ______________
If Bullying Verified, Have Invitation to Meetings Been Sent to Parents of Students
Involved?
Parents’
Parents’
Parents’
Parents’
Names:
Names:
Names:
Names:
_____________________________ Date
_____________________________ Date
_____________________________ Date
_____________________________ Date
Sent:______________
Sent:______________
Sent:______________
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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