Major Infraction Referral Form - Jensen Beach Elementary School
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1JENSEN BEACH ELEMENTARY SCHOOL
MAJOR INFRACTION REFERRAL FORM
NAME: ____________________________________
LOCATION
9Office 9 Bathroom/Restroom
9Cafeteria
DATE: __________________ TIME: ______________
9Ext. Day9Media Center
9 Field Trip
9 Special Event
9Related Arts
9Hallway
TEACHER: ______________GRADE:____________
9Assembly
9Bus Zone
9 Dismissal
9 Playground
9Classroom
9On Bus #___
REFERRING STAFF: _________________________
9 Arrival
9 Other _______________________
PROBLEM BEHAVIOR
POSSIBLE MOTIVATION
ADMINISTRATIVE DECISION
Check one þ
Check one þ
THIS WILL BE CHECKED BY ADMINISTRATION.
9 Abusive language/inappropriate
9 Obtain peer attention
9 Individualized instruction/behavior plan
language/ profanity
9 Obtain adult attention
9 Conference with student
9Defiance/disrespect/insubordination/non
compliance
9 Obtain items/activity
9Parent contact
9Disruption
9avoide peer (s)
9 Time in office
9Fighting/physical aggression
9 Avoid adult
9Loss of privelege
9 Lunch detention
9Harassament/tease/taunt
9Avoid task or activity
9Recess detention
9Lying/cheating
9 Don’t Know
9 After School detention
9Vandalism/property damage
9 Other _________________
9 InSchool Suspension
9Weapons or drugs
9 OutofSchool Suspension
9 Other _________________
9 Other ______________________
Reason for Referral: ______________________________________________________________________
OTHERS INVOLVED:
9none
9peers
9staff
9teacher 9substutitue
9 unknown
9 other ___________________
If suspended, for _______ days beginning ____________________ thorugh _______________________
Beginning date
Last day of suspension
9 Parent conference is requested. Please call 2191555.
ADMINISTRATOR SIGNATURE AND DATE: __________________________________________________
PARENT SIGNATURE AND RETURN TO SCHOOL IS REQUIRED TOMORROW.
PARENT/GUARDIAN SIGNAUTRE:__________________________________________ DATE: _________
White copy – Office
Yellow Copy – HR Teacher
Pink Copy – Parent
Gold Copy – Referring Teacher
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