SAMPLE DISCIPLINE REPORT

Date: ________________________ Day:  M T W Th F

OFFICE REFERRAL

Student: ________________________________ Gender: F /  M             504/IEP:  Y /  N

Homeroom Teacher: ______________________________ Time: _____________ AM / PM

Referring Staff Member: _______________________Location of Incident: ____________

Suspected Function of Behavior:______ Get Attention or _______ Avoid Work/Recess, Other

Referring Staff Member should mark Section A or B depending on the infraction/s being reported.

A.  The student displayed the following misbehavior, resulting in an immediate referral:

___ Physically Dangerous    Please specify: ______________________________________

___ Illegal Acts                 __________________________________________________

___ Defiance    __________________________________________________

B . Habitual infractions of Guidelines for Success that are checked below:

GUIDELINES FOR SUCCESS:

BE RESPONSIBLEBE RESPECTFUL

___ Failure to follow classroom rules___ Bullying

___ Possession of unauthorized item___ Disrespectful to authority figure

___ Profanity/Obscene gestures___ Lying

BE A TEAM PLAYERBE WILLING TO LEARN

___ Disruptive behavior___ Cheating

___ Violation of dress code___ Failing to complete assignments

___ Inappropriate use of school property___ Unprepared for class

The Teacher has used 3 or more of the following interventions or consequences:

___ Re-teaching (Practicing) correct behavior            ___ Time Out

___ Change seating___ Family Contact (phone, note, etc.)

___ Time Owed/Loss of Privilege___ Classroom meeting

___ Restitution___ Student/Teacher Conference

___ Recording Behavior on Daily Chart___ Check and Connect

___ Referral to Counselor___ Family Conference

Other: ____________________

C.  Actions Taken by Principal:

___ Self-monitoring plan___ Problem Solving Form

___ After School Detention                                      

___ MBC Room:                                                          ___ Loss of Privileges:

___ day(s)___ activity (e.g. restricted recess,

___ hour(s)computer time etc.)

___ period(s) specify___ peer interaction (not sitting

___ Family Involvement:with friends at lunch, etc.)

___ child calls parent___ Restitution:

___ staff calls parent___ school community service

___ parent meeting___ reimbursement of property

___ other: _______________________ apology letter/statement

___ Referral to AEP placement                                 ____Referral to Guidance Counselor

Principal Signature: ___________________Student Signature: ________________________

Parent Signature: _____________________Referring Staff Member Signature: __________