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  • 2014-2015 Behavior Referral Form Majors Only

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    This document is an office discipline referral form from Powell GT Magnet Elementary School. It contains fields to input a student's name and identifying information, the location and description of the problematic behavior, and the consequences assigned by an administrator. These may include interventions like behavior contracts, suspension from bus transportation, meetings with parents and students, in-school suspension, lunch detention, out of school suspension, or other actions. The form also allows the referring staff member to provide context like any prior preventative measures or discipline actions taken, and comments on the intrusive nature of the behavior. Parents are asked to sign the form acknowledging their receipt.

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    2014-2015 behavior referral form majors only

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    This document is an office discipline referral form from Powell GT Magnet Elementary School. It contains fields to input a student's name and identifying information, the location and description of the problematic behavior, and the consequences assigned by an administrator. These may include interventions like behavior contracts, suspension from bus transportation, meetings with parents and students, in-school suspension, lunch detention, out of school suspension, or other actions. The form also allows the referring staff member to provide context like any prior preventative measures or discipline actions taken, and comments on the intrusive nature of the behavior. Parents are asked to sign the form acknowledging their receipt.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    168 views2 pages

    2014-2015 Behavior Referral Form Majors Only

    Uploaded by

    api-31205600
    This document is an office discipline referral form from Powell GT Magnet Elementary School. It contains fields to input a student's name and identifying information, the location and description of the problematic behavior, and the consequences assigned by an administrator. These may include interventions like behavior contracts, suspension from bus transportation, meetings with parents and students, in-school suspension, lunch detention, out of school suspension, or other actions. The form also allows the referring staff member to provide context like any prior preventative measures or discipline actions taken, and comments on the intrusive nature of the behavior. Parents are asked to sign the form acknowledging their receipt.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as doc, pdf, or txt
    of 2

    Powell GT Magnet Elementary School Office Discipline Referral Form

    2. Location:

    3. Behavior:

    Choose 1

    Before/After School Care


    Bus
    Bus loop/dismissal locations
    Cafeteria
    Classroom
    Computer Lab
    Elective/Special
    Hallway/Breezeway/Courtyard
    Media Center
    Multi-purpose Room
    Off-campus _______________
    Office
    Playground
    Restroom

    4. Administrator Consequence:

    1-1 Noncompliance
    1-2 Disrespect
    1-4 Inappropriate Language
    1-6 Electronic Devices
    2-3 Violation of computer access
    2-4 Class/School Activity Disturbance
    2-6 School Transportation Disturbance
    2-11 Theft
    2-14 Harassment/Bullying
    2-16 Threat/False Threat
    2-17 Physical Aggression/Fighting
    3-2 Gang and Gang Related Activity

    Behavior Contract
    Bus suspension
    Contact/Conference with Parent
    Conference with Student
    ISS ______day(s) ______ day ________date
    Lunch Detention ______day(s)
    Out of School Suspension
    Silent Lunch ______day(s)
    Social Skills Instruction
    Other: _________________________________________________________

    1. Students Name: __________________________________________________________Date_________________ Time___________________


    Homeroom Teacher: ____________________________ Referring Staff:_________________________________________ Bus #___________________

    5. Prior Preventative Measures by referring staff: _________________________________________________________________________________________


    ___________________________________________________________________________________________________________________________________
    6. Prior Discipline Action by referring staff (Check all that apply): Think Sheet
    Parent Contact
    Time Out in supervised area
    Other Classroom Measures: ____________________________________________________________________

    7. Check one:

    __ 1st Major

    __ 2nd Major (Create Tier II Plan at PLT) __ 3rd + Major (Revise/Submit Tier III Request)

    Parent White & Yellow Copy

    Administration/Data Entry Pink Copy

    Referring Staff make a copy to keep

    8. Teachers Comments (Focus on the most intrusive behavior): ___________________________________________________________________________


    _________________________________________________________________________________________________________________________________________________

    9. Administrators Comments: _________________________________________________________________________________________________________


    ____________________________________________________________________________________________________________________________________
    Parents : Please sign below and return the yellow copy. You may keep the white copy for your records.
    Parent Comments: ________________________________________________________________________________________________________________________________
    Parent Signature: ______________________________________________________________________________________ Date: _____________________________________

    Parent White & Yellow Copy

    Administration/Data Entry Pink Copy

    Referring Staff make a copy to keep

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