School Discipline Referral Form

School Discipline Referral Form
Name: _________________________ Location Write offense number on the line.

Offense Number: 1___ 2___ 3___  Playground ____________  Library ___________
Teacher: _______________________  Cafeteria ____________  Bathroom __________
Grade: Pre-K K 1 2 3 4 5  Hallway ____________  Bus ____________
Referring Staff: _________________  Classroom ____________  Other ____________
Incident Write offense number on the line.

Problem Behavior Possible Motivation Administrative Decision
Minor
 Inappropriate language_______  Obtain peer attention________  Follow up agreement________
 Physical contact__________  Obtain adult attention________  Loss of privilege:
 Defiance__________  Obtain items/activities_______ ____________________
 Disruption____________  Avoid Peer(s) ___________ _________
 Property misuse___________  Avoid Adult___________  Conference with student______
 Homework ______________  Avoid task or activity________  Parent Contact__________
 Tardy ___________  Obtain item___________  Individualized instruction_____
 Other ___________________  Don’t know___________  Out-of-school suspension
______________  Other ____________________ (____hours/ days) _________
Major __________  Other ________________
 Abusive language__________ _________
 Fighting/ Physical
aggression____________
 Overt Defiance____________
 Harassment/bullying_________
 Disruption____________
 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
Description: ______________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Description: ______________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

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): _____________________________________

School Discipline Referral Form

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School Discipline Referral Form

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School Discipline Referral Form

Name: _________________________ Location Write offense number on the line.

Incident Write offense number on the line.

Others involved in incident: Write offense number on the line.

Principal Signature: _____________________________ Date: ______________

 I need to talk to the students’ teacher  I need to talk to the administrator

Parent/Guardian Signature: _________________________ Date: ____________

Offense 2: Date _______ Time _______

 I need to talk to the students’ teacher  I need to talk to the administrator

Parent/Guardian Signature: _________________________ Date: ____________

Offense 3: Date _______ Time _______

 I need to talk to the students’ teacher  I need to talk to the administrator

Parent/Guardian Signature: _________________________ Date: ____________

Name: __________________________ Date: __________________

2. What did you want?

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): _____________________________________

Name: __________________________ Date: __________________

2. What did you want?

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): _____________________________________

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Principal Signature: _______________ Date:

Parent/Guardian Signature: _____________ Date:

Offense 2: Date _ Time _

Parent/Guardian Signature: _____________ Date:

Offense 3: Date _ Time _

Parent/Guardian Signature: _____________ Date:

Name: ________ Date:

I will be _ by ______________

Name: ________ Date:

I will be _ by ______________