SDR

Savannah-Chatham County Public School System

Disciplinary Referral Form
NOTICE TO PARENT/GUARDIAN
This form references an incident involving your child that does not align with SCCPSS policies or Student Code of Conduct. The
incident and consequence are listed below. We appreciate your assistance with addressing this matter. It is important we work
together to ensure all students are provided a safe and quality learning environment.
Student Name: Student ID: School: Grade/Period: Student with Special Needs:
Yes No BIP in Place
No No Behavior in BIP
Parent Name: Contact Information: Date:
Reason for Referral: (Log Entry Text) Describe specific behavior of student, Motivation (Check One): Others Involved
attach additional sheets if needed. Avoid Adult None
Avoid Peers Peer
Avoid Task/Activities Staff
Don’t Know Teacher
Obtain Adult Attention Substitute
Obtain Items/ Activities Unknown
Obtain Peer Attention Other ______________
Bullying: Basis of Bullying:
Victim Race Sex
Aggressor Disability Other
Previous Action Taken/Consequence/Disposition:
Conference with Student Loss of Privileges Positive behavior support plan Saturday Detention Other
Conference with Parent/Guardian Changed Student’s Seat Before/after school detention Telephoned Parent
Meeting with Counselor Timeout Sent Letter Home Special Ed Procedures Followed
Reporter/Referral By: Incident Date Place of Incident:
and Time:
Administrator Use Only
Incident Type/Subtype/Category Title: Incident Code: Action Taken/Consequence/Disposition:
Incident Date (MM/DD/YYYY): Action Date Start Date (MM/DD/YYYY):
Incident Location Detail: Action Taken End Date (MM/DD/YYYY):
Duration/Number of Days (Assigned): Duration/Number of Days (Actual):
Local Disposition
200 Informational hearing/meeting with Student 230 Counseling 253 Physical Conflict Diversion Program

210 Telephone Parent/Guardian 240 Timeout or other

220 Conference with Parent/Guardian 251 Project Success

State Disposition
02 Detention Days 30 Out of School Suspension Days 00 Continuation of Action

20 In School Suspension Days 50 Denied Bus Transportation Days 95 Physical Restraint

70 Juvenile Court 480 Other Event Identifier:

Incident Context/Incident Location:
11 During Sch hrs/On Campus 12 During Sch hrs/Sch Sponsored/Off Camp 13 During Sch hrs/Sch Sponsored transportation 14 During school
21 Outside Sch hrs/ On Campus 22 Outside Sch Hrs/Sch Sponsor/Off Camp 23 Outside Sch hrs/ Sch Sponsored transportation hours, Off school
31 Outside Sch Hrs/Non-Sponsored 32 Outside Sch hrs/During Non-Sch 33 Outside Sch Hrs/During Non-Sch Sponsored Act/ campus/Non-
Act/On Campus Sponsored Act/Not on Sch Site/ Assoc w/Sch Not on Sch Site/Not Associated w/Sch sponsored activity
During disciplinary action did the student receive Incident Severity Level: 1Discipline/Due Process:
educational services? Yes No
Administrator/ID: Date: Entered into SIS by:
Comments: Student Signature (Secondary School Only):

1Due Process is required for Disposition Code of 30,40, and 61. For Disposition Code 40, Due Process is 01 or 02. For Disposition Code 30 or 61, Due Process is 01, 02, or 03.
2Request alternative school placement (Code 61)
3Request permanent expulsion (Code 40)
*Information about Behavior, Severity, Dispositions, and Due Process Codes can be found on ACORN: http://acorn/codes
4Only use for a local incident with a disposition of 30,31,33,34.
FORM 100-620-0018 Revised 12/21/2018