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School Discipline Referral Form

This document is a school discipline referral form. It contains fields to record a student's name, location and reason for the referral, as well as the referring staff member. [END SUMMARY]

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786 views3 pages

School Discipline Referral Form

This document is a school discipline referral form. It contains fields to record a student's name, location and reason for the referral, as well as the referring staff member. [END SUMMARY]

Uploaded by

api-449504614
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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School Discipline Referral Form

Name: _________________________ Location Write offense number on the line.


Offense Number: 1___ 2___ 3___  Playground ____________  Library ___________
Teacher: _______________________  Cafeteria ____________  Bathroom __________
Grade: Pre-K K 1 2 3 4 5  Hallway ____________  Bus ____________
Referring Staff: _________________  Classroom ____________  Other ____________

Incident Write offense number on the line.


Problem Behavior Possible Motivation Administrative Decision
Minor
 Inappropriate language_______  Obtain peer attention________  Follow up agreement________
 Physical contact__________  Obtain adult attention________  Loss of privilege:
 Defiance__________  Obtain items/activities_______ ____________________
 Disruption____________  Avoid Peer(s) ___________ _________
 Property misuse___________  Avoid Adult___________  Conference with student______
 Homework ______________  Avoid task or activity________  Parent Contact__________
 Tardy ___________  Obtain item___________  Individualized instruction_____
 Other ___________________  Don’t know___________  Out-of-school suspension
______________  Other ____________________ (____hours/ days) _________
Major __________  Other ________________
 Abusive language__________ _________
 Fighting/ Physical
aggression____________
 Overt Defiance____________
 Harassment/bullying_________
 Disruption____________
 Other ______________
____________

Others involved in incident: Write offense number on the line.


 None________  Peers________  Staff________  Teacher ________  Substitute_________
 Unknown _________  Other_________

Other comments:
________________________________________________________________________
________________________________________________________________________

Principal Signature: _____________________________ Date: ______________


Parent/Guardian Signature: _________________________ Date: ____________
All minors are filed with classroom teacher. Three minors equal a major.
All majors require administrative decision and parent signature.
Offense 1: Date _______ Time _______

Description: ______________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

 I need to talk to the students’ teacher  I need to talk to the administrator

Parent/Guardian Signature: _________________________ Date: ____________

Offense 2: Date _______ Time _______

Description: ______________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

 I need to talk to the students’ teacher  I need to talk to the administrator

Parent/Guardian Signature: _________________________ Date: ____________

Offense 3: Date _______ Time _______

Description: ______________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

 I need to talk to the students’ teacher  I need to talk to the administrator

Parent/Guardian Signature: _________________________ Date: ____________


Follow up Agreement

Name: __________________________ Date: __________________


1. What rule(s) did you break? (Circle)
Be Safe Be Respectful Be Responsible

2. What did you want?


I wanted attention from others I wanted to be in control of the situation
I wanted to challenge adult(s) I wanted to avoid doing my work
I wanted to be sent home I wanted revenge
I wanted to cause problems because I feel miserable inside
I wanted to cause others problems because they don’t like me
I wanted _________________________________________

3. Did you get what you wanted? yes no

4. What will you do differently next time?

I will be _____________________________ by __________________________________________

_________________________________________________________________________________

5. Student signature: __________________________________________

6. Adult signature(s): _____________________________________

Follow up Agreement

Name: __________________________ Date: __________________


1. What rule(s) did you break? (Circle)
Be Safe Be Respectful Be Responsible

2. What did you want?


I wanted attention from others I wanted to be in control of the situation
I wanted to challenge adult(s) I wanted to avoid doing my work
I wanted to be sent home I wanted revenge
I wanted to cause problems because I feel miserable inside
I wanted to cause others problems because they don’t like me
I wanted _________________________________________

3. Did you get what you wanted? yes no

4. What will you do differently next time?

I will be _____________________________ by __________________________________________

_________________________________________________________________________________

5. Student signature: __________________________________________

6. Adult signature(s): _____________________________________

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