Healthy Environments in Schools Action Team (HESAT)

Sample Forms/Letters

This section contains samples of forms and letter that schools are currently using to deal with dating and sexual violence issues and bullying. It also contains notification letters and agreements about student contact.

    Example Forms:
  • School Policy on interpersonal violence
  • Notice of Parent and student rights
  • Student complaint form
  • Student on student Altercation response chart
  • Stay away agreement
  • A Guide to Addressing Dating Violence in Texas Schools : The Texas Dating Violence Prevention Team, a group of non-profits and government agencies, developed this document by pulling from several national model programs. We hope it will help you to supplement your school district's new policies by creating a comprehensive dating violence program.
  • Bullying, Sexual Harassment, Dating Violence Student Complaint Form from Houston, TX public schools : A counselor or administrator who receives a report of bullying, sexual harassment, or dating violence will address the following issues with the student who was the target of the reported behaviors in a private meeting before assisting the student to complete the Complaint Form.
  • Cambridge Public Schools Domestic Violence and Teen Dating Violence Administrative Guidelines : As detailed in the Cambridge Public Schools Policy Against Domestic Violence and the Cambridge Public Schools Policy Against Teen Dating Violence, the Cambridge Public Schools is committed to providing a learning environment in which domestic violence and teen dating violence are not tolerated. Consistent with this philosophy, the Cambridge Public Schools is committed to promoting an environment free from domestic violence and teen dating violence. Accordingly, the Cambridge Public Schools seeks to increase awareness of domestic violence and teen dating violence and help in responding to the needs of victims and children who are witnesses to such violence.
  • Model Teen Dating Violence Policy : A sample policy for use in schools, community centers, etc. Covers definitions, victim safety, training and prevention, and intervention in schools.
  • NOTICE OF PARENT AND STUDENT RIGHTS: BULLYING AND HARASSMENT from Austin, TX School District : The Austin Independent School District (AISD) is committed to providing a positive learning environment for all students that enhances personal safety and promotes respect, dignity and equality among students. High standards are expected for both academic achievement and for behavior.
  • NOTICE OF PARENT AND STUDENT RIGHTS: BULLYING, SEXUAL HARRASSMENT, DATING VIOLENCE, AND SEXUAL VIOLENCE from Weatherford, TX : All charges of bullying, sexual harassment, dating violence, and sexual violence are to be taken very seriously by students, faculty, staff, administration, and parents/guardians. WISD will make every effort to handle and respond to every charge and complaint filed by students and employees in a fair, thorough, and just manner. Every effort will be made to protect the due process rights of all victims and all alleged perpetrators.

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