JGA-1 Form
Revised: 8-10-11, 6-14-23
VERIFICATION OF PARENT OR GUARDIAN CONTACT REGARDING THREAT OR INCIDENT
I, [Name] , principal or principal’s designee, contacted [Name of parent or guardian] on [Date] and notified him or her that [Name of student] has made suicidal threats or was involved in an incident of bullying, hazing, cyber-bullying, abusive conduct, or retaliation. Contact was made:
[ __ ] in person
[ __ ] by telephone (number used: ____________________)
[ __ ] by email (email address used: ____________________)
[ __ ] by other method (specify): ______________________
Notice was given of:
[ __ ] suicide threat
[ __ ] bullying incident
[ __ ] cyber-bullying incident
[ __ ] abusive conduct incident
[ __ ] hazing incident
[ __ ] retaliation incident
[Name of school staff member]_______ , witnessed the contact.
_________________________ __________________ _______________
Principal or Principal’s Designee Title Date
_________________________ ___________________ ________________
School Staff Member Title Date
