Stop and Think Form (updated 2/13/17)

Student Name__________________________Date__________Section_______

Teacher Name ____________________________

Describe the incident:

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

What was the poor decision that you made? (Check all that apply)

______ Disrupted class with unnecessary talking/noises.

______ Talked back to teacher
______ Inappropriate language
______ Harassment or bullying
______ Disrespect (verbally or nonverbally)
______ Refused to cooperate when asked (Insubordination)
______ Not actively/appropriately participating in class.
______ Cell phone
______ Other ________________________________________________________________

Whom did your poor decision impact?

______ Teacher or Staff Member

______ One or two students
______ Entire class
______ Other ________________________________________________________________

How do you think your choices impacted those around you?

______ Frustrated
______ Hurt/ Humiliated/ Embarrassed
______ Distracted
______ Increased work/effort
______ Decreased work time
______ Insulted
Other:

What 2 actions will you take to improve this situation?

Write 2 better choices you could make.

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Which level are you at after this Stop and Think? (Check only 1)

1. Warning _____ 2. Office Referral _____

________________________ _______________________________
Student Signature Teacher Signature