Student Name: _________________________________

Period _____

Date

Verbal Warnings in class (1 & 2)

_______

[ ] Speaking during classroom instruction.

[ ] Other. ______________________________________

_______

[ ] Speaking during classroom instruction.

[ ] Other. ______________________________________
Verbal Warning - Private (3)

_______

[ ] Speaking during classroom instruction.

[ ] Other. ______________________________________

Writing Reflection by student (4)

_______

[ ] Speaking during classroom instruction.

[ ] Other. ______________________________________

Call or meet with parent/guardian (5)

_______

[ ] Speaking during classroom instruction.

[ ] Other. ______________________________________

Send student to office with discipline referral (6)

_______

[ ] Speaking during classroom instruction.

[ ] Other. ______________________________________

Dear Student,
You are being asked to write about your conduct in the classroom. The
reason is because its consequences are disrupting classroom instruction.
Your disruptive conduct continues despite you having received two in class
verbal warnings and one private conversation with your teacher with the
intention of correcting your conduct
Please answer the following questions in complete sentences.
Thinking of my conduct and its consequences.
What am I doing that disrupts class instruction?
Who was involved?
Why did I choose to conduct myself in this manner?
What consequences does this conduct have on my ability to learn and on my
parents or guardians?
What consequences does this conduct have on my classmates ability to learn
and on their parents and guardians?
What are the consequences of this conduct on my teacher?
Plan for Improvement
What will I do to improve my conduct?
--------------------------------I will return my responses and meet with Mr. Villarreal on the following date:
_________ / ________ / _____________
I understand that if I do not meet with my teacher, Mr. Villarreal, he will
contact my parents or guardians.
Student: __________________________

Date: _________

Teacher: __________________________

Date: _________