School Discipline Referral Form

School Discipline Referral Form Name: _________________________ Offense Number: 1___ 2___ 3___ Teacher: _______________________ Grade: Pre-K K 1 2 3 4 5 Referring Staff: _________________

Location Write offense number on the line.  Playground ____________  Cafeteria ____________  Hallway ____________  Classroom ____________

Incident Write offense number on the line. Problem Behavior Possible Motivation Minor  Inappropriate language_______  Physical contact__________  Defiance__________  Disruption____________  Property misuse___________  Homework ______________  Tardy ___________  Other ___________________ ______________ Major  Abusive language__________  Fighting/ Physical aggression____________  Overt Defiance____________  Harassment/bullying_________  Disruption____________  Other ______________ ____________

        

Obtain peer attention________ Obtain adult attention________ Obtain items/activities_______ Avoid Peer(s) ___________ Avoid Adult___________ Avoid task or activity________ Obtain item___________ Don’t know___________ Other ____________________ __________

 Library ___________  Bathroom __________  Bus ____________  Other ____________

Administrative Decision  Follow up agreement________  Loss of privilege: ____________________ _________  Conference with student______  Parent Contact__________  Individualized instruction_____  Out-of-school suspension (____hours/ days) _________  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: __________________________ 1. What rule(s) did you break? (Circle) Be Safe Be Respectful

Date:

__________________

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?

4.

What will you do differently next time?

yes

no

I will be _____________________________ by __________________________________________ _________________________________________________________________________________ 5.

Student signature: __________________________________________

6.

Adult signature(s): _____________________________________

Follow up Agreement Name: __________________________ 1. What rule(s) did you break? (Circle) Be Safe Be Respectful

Date:

__________________

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?

4.

What will you do differently next time?

yes

no

I will be _____________________________ by __________________________________________ _________________________________________________________________________________ 5.

Student signature: __________________________________________

6.

Adult signature(s): _____________________________________