I use this document when there are problems among peer groups in my class, which happens A LOT in middle school. It’s important to know that there are 3 sides to every story: student A, student B, and the truth. This document allows for students to reflect and tell their side to the story. I usually verbally talk to my students before giving this to them to mediate the peer conflict. After the conflict has been resolved, I then have all parties fill out this reflection sheet. I especially love the part where they choose their zone of regulation. This reinforces Social/Emotional learning, which is extremely important to me!
I keep a record of the reflections in a file folder for later reference, especially when repeated behaviors happen. I can then show my documentation and evidence to parents and administration when issues arise.
I have included the PDF version along with a link to the electronic google doc version, so you can edit it to your liking. Simply, click file --> make a copy to edit. Enjoy!