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 *
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Number of Students in Dispute *
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.)
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