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Conflict Resolution/Peer Mediation   

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HAYWARD UNIFIED SCHOOL DISTRICT

INSTRUCTION DIVISION

STUDENT SERVICES

CONFIDENTIAL NOTICE REGARDING STUDENT BEHAVIOR

To: Date:

Student Name:

Birth date: Grade: _______________________

Current law (Education Code Section 49079a), requires that teaching personnel be informed regarding a student who has caused, or attempted to cause, serious bodily injury or injury as defined in Penal Code Section 243, to another person.

* The information provided pursuant to this section is received in confidence for the limited purpose provided and shall not be further disseminated by the teachers.

* This information is to be maintained for a 3-year period beginning July 1, 1990.

YOU ARE ADVISED TO REVIEW THE SEPARATE CONFIDENTIAL FILE OF THE STUDENT LISTED ABOVE LOCATED AT THE SCHOOL SITE

Please sign and return this form to the school principal.

Signature Date

Teacher/Counselor

Signature Date

Teacher/Counselor

Signature Date

Teacher/Counselor

Signature Date

Teacher/Counselor

Signature Date

Teacher/Counselor

Signature Date

Teacher/Counselor

Exhibit HAYWARD UNIFIED SCHOOL DISTRICT

version: June 1992 Hayward, California

___________________________________________________________________________Exhibit 2

5138

CONFLICT RESOLUTION/PEER MEDIATION

Exhibit A

CONFIDENTIAL INFORMATION REGARDING STUDENT CONDUCT

Student Name:

Birth date: Grade: ______________________

Current law (Education Code Section 49079a) requires that teaching personnel be informed regarding a student who has caused, or attempted to cause, serious bodily injury or injury as defined in Section 243 of the Penal code, to another person.

* The information provided shall be received in confidence for the limited purpose provided and shall not be further disseminated by the teacher.

* This information shall be maintained for a 3-year period beginning July 1, 1990.

* P.C. 243 (e)

(5) "Serious bodily injury" means a serious impairment of physical condition including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of function of any bodily member or organ; a wound requiring extensive suturing; a serious disfigurement.

(5) "Injury" means any physical inquiry which requires professional medical treatment.

Date of Offense:

Location of Offense:

Brief Description of Offense:

Child Welfare and Attendance Supervisor Date

(File in separate confidential school file)

DISTRIBUTION: WHITE: CWA

YELLOW: PRINCIPAL

PINK: CENTRAL FILES

Exhibit HAYWARD UNIFIED SCHOOL DISTRICT

version: June 1992 Hayward, California