Student Reflection
Please fill out the form. If there are any questions please ask the supervisor.
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First name:
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Your answer
Last name:
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Your answer
Grade:
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Choose
6
7
8
What happened? (Who was involved, where did this happen, describe the situation in detail, who initiated the issue/conflict.)
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Your answer
How were you feeling at the time of the incident?
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Happy
Sad
Angry
Embarrassed
Scared
Other
Required
How have you been affected by this?
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Your answer
Have others been affected by this incident? If so, how?
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Your answer
What needs to happen to help resolve this issue? (What needs to happen to help make things right?)
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Your answer
Create a three (3) step plan to avoid this happening in the future.
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Your answer
Here are some ways I could have helped avoid this situation:
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Keep my voice calm.
Compromise with the other person.
Walk away.
Ask a teacher for help problem solving about this.
Ask a parent for help figuring out how to deal with this.
Talk to my school counselor.
Talk to a trusted adult.
Be responsible
Be respectful
Be ready
Other:
Required
Is there anything else you'd like to share?
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Your answer
How can staff better support you in the future in the future?
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Your answer
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