Student Discipline Referral - The School District Of Palm Beach County
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1THE SCHOOL DISTRICT OF PALM BEACH COUNTY
Student Discipline Referral
DIRECTIONS: Write in the appropriate code number or letter in the corresponding boxes.
ESE/504
Student Name (First, Middle Initial, Last)
Student Number
Grade
Date
Military Time
Yes
No
Location
Report By
School
Bus Code
BK
- Bookstore
BS
- Bus Stop
3-Digit Staff I.D.
BU
- School Bus/Transportation
Corrective Strategies/Interventions Prior to Referral (include date)
Loss of Incentives
Conference With:
CA
- Cafeteria
CL
- Clinic
Detention
Student
SBT Referral
CS
- Regular Classroom
GR
- School Grounds
Reported By (Code) (Use
Assigned Mentor
Parent/Guardian
Mediation
GY
- Gymnasium
number below for those
HA
- Hallway
persons w/o
Reflective Assignment
Counselor
Student Contract
IS
- Alternative to Suspension
a staff ID.)
Room
Reteach/Model Expectations
Other
BIP
975
- Paraprofessional
LA
- Laboratory
976
- Bus Driver
LI
- Library/Media Center
Description
of Event (be specific)
Severe Offense
977
- Clerical
OF
- Office
978
- Crossing Guard
OG
- Off School Grounds
979
- Custodian
OT
- Other
980
- Food Service Staff
PG
- Playground/Track
981
- Law Enforcement Officer
PK
- Parking Lot
982
- Parent/Guardian
RE
- Rest room
983
- Student
RT
- Returning Home
984
- Substitute Teacher
TO
- Field Trip/Activity
985
- School Volunteer
Off Campus
999
- Other
TR
- To School
ADMINISTRATIVE USE ONLY BELOW THIS LINE
District Number
When Event Occurred (check one)
Where Event Occurred (check one)
Related Issues (check all that apply)
Bullying
DISTRICT 50
1
• DURING SCHOOL HOURS
G
-
Gang
H -
Hate
Harassment
1
• SCHOOL GROUNDS/ ON CAMPUS
If not 50, provide District No.
related
related
2
-
Outside school
hours,
school
sponsored activity
Based On:
2
- Sponsored activity/off campus
W -
Weapon
School No.
0
· Drug
R
S
D
3 - Outside school
hours,
non-school sponsored activity
related
3 -
School sponsored transportation
related
HOME SCH.
(includes bus stops)
SO
RE
A-
Alcohol
related
4 - Unrelated
event
or
unknown
If not home school provide School No.
Incident Codes
Administrator's Name
Administrator's I.D. Event Number
Date
If Weapon Used What Kind?
ALL
(see code sheets)
K -Knife
H - Handgun
Comments
Law Enforcement Notified
O - Other
F -Firearm/Explosive
Weapon
Device
U - Unknown
R - Rifle/Shotgun
Signature of Parent
Date
Duration
TRESPASSING
NOTICE:
I,
the student, am aware that I may
not
be
Action Codes
How many days?
ALL
on
school grounds and may not attend any school
functions
or
(see code sheets)
Begin Date
school
activities
on or off school grounds of any
Palm
Beach County
School
District
facility during the dates of
my
suspension.
Return Date
Case Number/Agency
Yes
No
CRT/PCM Team Intervention
Signature of Student
Date
PBSD 0279 (Rev. 5/19/2016)
RECORD COPY - Administration
COPY - Parent
COPY - Originator
COPY - Guidance Counselor / ESE Contact
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