Student’s Name:
Grade Level:
Classroom/Homeroom Teacher:
Room Number:
Plan Start Date:
Proposed End Date:
All School/Staff:
1. All necessary school staff will be apprised of this safety plan and will make every effort to implement it successfully.
2. Any school staff who witness or are otherwise made aware of any harassing, intimidating, bullying or retaliatory behavior toward the student will intervene immediately and will report such behavior to the principal.
Roles and Responsibilities:
Please have identified individual initial next to their role to signify awareness and understanding of their responsibilities.
1. The alleged target will not have contact with the accused/student engaged in bullying behavior – not face-to-face, not by phone, not online, or by any other mean- while this safety plan is in effect.
(Initials)
2. Parent(s)/legal guarding of targeted student agrees to take all necessary precautions to ensure target’s safely off-campus and/or outside of the regular school day. (Initials)
3. Mr./Mrs. will be designated as the student’s primary point of contact on staff. The primary of point of contact will be responsible for checking in with the student every day to ensure the safety plan is working. This contact is intended to be pro-active in nature and does not involve the student being responsible for locating or making contact with the staff member. The staff member initiates this contact. Additionally, the conversations should occur in a private location. (Initials)
4. Mr./Mrs. is designated as the student’s back up point of contact. The back- up point of contact has all the same responsibilities as the primary point of contact when that person is absent. The primary point of contact is responsible for informing the back-up point of contact when they are absent. (Initials) (Initials)
5. The student will report any breach of this plan to his/her parents, designated point of contact, teacher or other staff person immediately. (Initials)
6. The student will also report any such behavior which occurs as a result of this plan off-campus and/or outside of the regular school day. (Initials)
7. Mr./Mrs. the classroom teacher, will keep the student and the accused/student engaged in bullying behavior separated in the classroom and during all class activities. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the designated bullying investigator as soon as possible.
(Initials)
8. All classroom teachers will keep the student and the accused/student engaged in bullying behavior separated in the classroom and during class activities. If the student and the accused/student engaged in bullying behavior are in multiple classes together, a separate sheet identifying the classroom teacher and the responsibilities in #7 will be initialed and attached to this plan. (Initials)
9. Bothe the alleged target’s and the accused’s/student engaged in bullying behaviors schedules will be reviewed with the target and their parent/legal guardian. Possible points of interaction will be identified. Additionally, the alleged target will provide all the necessary information about items and places where they see the accused/student engaged in bullying behavior to ensure staff are present during before- school activities, during the school day and during after-school activities to ensure the student’s safety. Appropriate staff members will be identified and apprised of the safety plan. Those staff members will be visible in the hall and will monitor the student during all passing times. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the designated bullying investigator as soon as possible. A separate sheet identifying those staff members will be initialed and attached to this plan. (Initials)
10. If bullying is alleged during recess, Mr./Mrs. is designated as the student’s recess monitor and will be visible and available during recess. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the designated bullying investigator as soon as possible. (Initials)
11. If bullying is alleged during lunch, Mr./Mrs. is designated as the student’s lunch monitor and will be visible and available during lunch. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the designated bullying investigator as soon as possible. (Initials)
12. If bullying is alleged during physical education class, Mr./Mrs. is designated as the student’s Gym class monitor and will be visible and available during Gym. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the designated bullying investigator as soon as possible. (Initials)
13. If bullying is alleged during extra-curricular activities, including athletics, Mr./Mrs. is designated as the extra-curricular monitor and will be visible and available during extra0curricular activities. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the designated bullying investigator as soon as possible. (Initials)
14. If bullying is alleged during the bus ride to or from school, the bus personnel will be instructed to intervene immediately in any incident of harassment, bullying, intimidation and or retaliation involving the student and to report any bus incidents immediately to the school principal or to dispatch, who will then be responsible for reporting to the principal. (Initials)
15. The school will immediately report any incidents of bullying, harassment, intimidation and/or retaliation to the student’s parent(s)/legal guardians. (Initials)
This plan is in place from through , at which time it will be reviewed, revised or continued, if necessary.
We agree to the safety plan as stated above.
Student: Date
Principal: Date
UPLOAD FORM