Name _____________________
Date _____________________
What happened?
Who was involved?
Why did this happen?
What was going through your head when this was going on?
Name _____________________
Date _____________________
How do you think the teachers and staff felt?
How do you think it made your peers feel?
What should be the consequences?
How do we ensure this does not happen again?
Student Signature: _____________________
Parent Signature: _____________________
Teacher Signature _____________________