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. Student is not to have contact with targeted student in any way. Student is not to speak to targeted student, interact with targeted student, make derogatory, insulting or threatening remarks in the targeted student’s presence, display any insulting gestures, contact or reference targeted student using social media or engage or direct other students to harass or bully targeted student. Student is not to intimidate, bully or harass targeted student in any capacity.
2. If bullying occurred prior to the start of the school day, when student arrives in the building, he/she will report immediately to the main office. Student will not leave office until the adult escort arrives. Mr./Mrs. will serve as the adult escort. (Initials)
3. Mr./Mrs. , the classroom teacher, will keep the targeted student and the student engaged in bullying separated in the classroom and during class activities. Any and all incidents of harassment/bullying/intimidation/retaliation will immediately be addressed and then reported to the designated bullying investigator. If target and student have multiple classes together, all teaching staff associated with the class will be added onto a separate, attached sheet and given the same responsibility to separate the students and address any problematic behavior. (Initials)
4. Classroom teachers will keep the targeted student and the student engaged in bullying behavior separated in the classroom and during class activities. Teachers will immediately intervene, address and report any and all incidents of harassment/ bullying/ intimidation/ retaliation to the designated bullying investigator. (Initials)
5. If bullying occurred during passing periods, student engaged in bullying is now on delayed passing until the safety plan expires. Mr./Mrs. will escort the student engaged in bullying from class to class. Student will not exit the class until the adult escort has arrived. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the administration as soon as possible. (Initials)
6. Appropriate staff will be advised of the student safety plan, visible in the hallways and monitoring the student engaged in bullying at all times. Any bullying, intimidation, harassment and/or
7. retaliation will be addressed immediately and reported to the administration as soon as possible. (Initials)
8. If bullying occurred during recess, Mr./Mrs. is designated as the student’s recess monitor and will be visible and vigilantly monitoring student’s conduct during recess. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the administration as soon as possible. (Initials)
9. If bullying occurred during lunch, Mr./Mrs. is designated as the student’s lunch monitor and will be visible and vigilantly monitoring student’s conduct during lunch. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the administration as soon as possible. (Initials)
10. If bullying occurred during physical education class or in the locker room before or after physical education class, Mr./Mrs. is designated as the student’s gym class monitor and will be visible and vigilantly monitoring student’s conduct during gym class and before or after gym class in the locker room. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the administration as soon as possible. (Initials)
11. If bullying occurred during extra-curricular activities, including athletics, Mr./Mrs. is designated as the extra-curricular monitor and will be visible and available during extra-curricular activities. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the administration as soon as possible. (Initials)
12. If bullying occurred on the bus either before or after school, student will have an assigned seat on the bus, closest to the bus driver. The bus driver will be instructed to separate the student engaged in bullying and the targeted student, intervene immediately and to report any bus incidents immediately to either the building principal or dispatch, who will then report the incidents to the building principal. Any bullying, intimidation, harassment and/or retaliation will be addressed immediately and reported to the administration as soon as possible. (Initials)
13. If the student walks home and has engaged in bullying behavior on the way home, student will receive a 15-minutes after-school detention until the plan expires. (Initials)
14. The school will immediately report any incidents of bullying, harassment, intimidation and/or retaliation to the student’s parents/legal guardians. (Initials)
This plan is in place from through , at which time it will be reviewed, revised or continued, if necessary.
Any violation of the safety plan will result in more severe disciplinary action, up to and including dismissal, removal or expulsion.
We are aware of the expectations of the safety plan as stated above.
Student: Date
Principal/Administrator: Date
Approved: January 2007
Reviewed: April/May 2014
Revised: April/May 2014
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