Student behavior form

When a student gets written up 3 to 4 times, automatically gets in trouble and parents will be called. for more information please call

239-299-3682

School Discipline Referral Form

Name: _________________________ Location Write offense number on the line.

Offense Number: 1___ 2___ 3___ 4__ ( Playground ____________ ( Library ___________

Teacher: _______________________ ( Cafeteria ____________ ( Bathroom __________

Grade: 9 10 11 12 (Graduate) ( Hallway ____________ ( Bus ____________

Referring Staff: _________________ ( Classroom ____________ ( Other ____________

Incident Write offense number on the line.

Problem Behavior

Possible Motivation

Administrative Decision

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 ____________________

__________

• 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: __________________________ 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): _____________________________________