Fillable PARENT/GUARDIAN NOTIFICATION RECORD OF STUDENT BULLYING INCIDENT OR

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PARENT/GUARDIAN NOTIFICATION RECORD OF STUDENT BULLYING INCIDENT OR

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Country of origin: US
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PARENT/GUARDIAN NOTIFICATION RECORD OF
STUDENT BULLYING INCIDENT OR SUICIDE THREAT
In accordance with Utah Code Ann., Section 53A-11a-203
This is a record documenting notification given to a parent/guardian of a bullying, cyber-bullying,
harassment, hazing, or retaliation incident; or suicide threat involving their student. This form must be
maintained securely, confidentially, and separately from the student’s educational records by school
administration consistent with
Utah Code Ann., Section 53A-11a-203(3). DO NOT USE THIS FORM
TO NOTIFY A PARENT/GUARDIAN OF THE BULLYING INCIDENT OR SUICIDE THREAT.
Student Information
Student Name:
School:
Parent Information
Parent/Guardian Name:
Contact Date:
Contacted VIA:
Phone
Number:
Time:
a.m. p.m.
Personal Contact:
Time:
a.m. p.m.
Email
Address:
(Attach copy of email)
Mail
Address:
(Attach copy of letter)
Other
Incident Information
Incident Type:
Bullying Cyber-bullying Harassment Hazing Retaliation Suicide
Incident/Threat
Date:
Printed Name of School Administrator
School Administrator Signature
Version: 2013-08-JDD/GBEA
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PARENTGUARDIAN NOTIFICATION RECORD OF STUDENT BULLYING INCIDENT OR

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Completed 7 December 2021

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