School *

Case referred by Staff or Student *

Date of Mediation *

Number of Students in Dispute *

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

Location of Dispute *

Type of Conflict *

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.)