TEACHER DISCIPLINE REFERRAL

STUDENT INFORMATION

LOC Last Name First Name MI Grade Student I.D. Date of Birth Date
Gender Student Address Home Phone
M F Parent/ Guardian Business Phone
School Thomas Jefferson High School
CHECK IF APPROPRIATE: Federal Lunch Program: Ethnicity:
Special Education □ Free □ American Indian x Hispanic
M/M Transfer □ Reduced □ Asian/Pacific Islander □ Anglo/White
504 □ African-American (Black)

This form is to be used for referrals to the principal or designee for violations of classroom/local campus rules or violations of the
Student Code of Conduct.

Indicate type of referral below:

Student Code of Conduct Violation

Description of Student's Behavior(s) Date of Incident(s)

Previous Action Taken: (Include Parental Contacts) Date of Incident(s)

Description of Action:

Attach any additional documentation Teacher: Date:

Administrative Disposition-Action Taken:

Type of Parent/Guardian Contact:

Campus Level Conference/Date(s):
Formal Conference/Date(s):
Expulsion Hearing/Date(s):