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.
Bullying Cyber-bullying Harassment Hazing Retaliation Suicide
Printed Name of School Administrator
School Administrator Signature
Version: 2013-08-JDD/GBEA