Shadow Student Athletes A.I.M. Mediation Form
Requester (First Name, Last Name)
Your answer
School
Date
MM
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DD
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YYYY
Disputant 1 Name (First, Last)
Your answer
Disputant 1 Phone
Your answer
Disputant 1 Grade
Disputant 1 Gender
Disputant 1 Race
Disputant 2 Name (First, Last)
Your answer
Disputant 2 Phone
Your answer
Disputant 2 Grade
Disputant 2 Gender
Disputant 2 Race
Disputant 3 Name (First, Last)
Your answer
Disputant 3 Phone
Your answer
Disputant 3 Grade
Disputant 3 Gender
Disputant 3 Race
Disputant 4 Name (First, Last)
Your answer
Disputant 4 Phone
Your answer
Disputant 4 Grade
Disputant 4 Gender
Disputant 4 Race
Type of Dispute (select all that apply)
Brief Description of Dispute
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FOR SHADOW STAFF ONLY Description Mediation Outcome
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FOR SHADOW STAFF ONLY Current Risk Level
FOR SHADOW STAFF ONLY Conclusion
FOR SHADOW STAFF ONLY Period Mediation took place
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FOR SHADOW STAFF ONLY Length of Mediation (in hours and minutes)
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FOR SHADOW STAFF ONLY Date of Mediation
MM
/
DD
/
YYYY
FOR SHADOW STAFF ONLY Next steps
FOR SHADOW STAFF ONLY Form Completed by (First, Last)
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