Request edit access
Bulloch County System School Peer Mediation Report
Please complete this form to document the mediation.
School *
School where mediation was held.
Case referred by Staff or Student *
Date of Mediation *
MM
/
DD
/
YYYY
Number of Students in Dispute *
Your answer
Disputant Details
Disputant 1 - Gender *
Disputant 1 - Grade *
Disputant 1 - Race *
Disputant 2 - Gender *
Disputant 2 - Grade *
Disputant 2 - Race *
Disputant 3 - Gender
Disputant 3 - Grade
Disputant 3 - Race
Disputant 4 - Gender
Disputant 4 - Grade
Disputant 4 - Race
Disputant 5 - Gender
Disputant 5 - Grade
Disputant 5 - Race
Disputant 6 - Gender
Disputant 6 - Grade
Disputant 6 - Race
Dispute details
Location of Dispute *
Required
Type of Conflict *
Required
Mediation details
Administrator/Staff Mediated? *
Length of Mediation *
Signed Mediation Contract? *
Agreement Kept? Was agreement still in force a month later? If students had to be referred to Peer Mediation a second time or if there was another administrative referral, then the agreement has not been kept. *
Would the students have fought if not mediated (According to student evaluation form)? *
Other disciplinary actions taken? (OSS, ISS?) *
If other disciplinary action was taken, please note the type here (out of school suspension, in school suspension, expulsion, etc.)
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of Mediation Center of the Coastal Empire. Report Abuse - Terms of Service