Form Tra0040 - Bus Safety Referral printable pdf download

St. Lucie Public Schools

Bus Safety Referral

Student Name: _________________________________________________ Student ID #: __________________________________

School: ______________ Grade: _______ Gender:

Incident Date: ______________ Time: _________ Bus # _________

____________

Check if applicable:

Student has an IEP

Student has a 504 Plan

Student has a Behavior Plan

DETAILED description of incident (Include WHO, WHAT, WHEN, WHERE, WHY): _________________________________________

___________________________________________________________________________________________________________

Context of incident (check one):

1 During school hours

2 Outside school hours-school sponsored activity

3 Outside school hours-non-school sponsored activity

Where incident occurred (check one):

1 School grounds/on campus

2 School-sponsored activity/off campus

3 School-sponsored transportation (including bus stops)

School where incident occurred if other than home school: ______________________________________________

9001 Non-school location

Incident Location (check one):

AT Activity Trip

BS Bus Stop

CL Classroom

HL Hallway

OF Office

RR Restroom

99 Unknown

AU Auditorium

BU School Bus

FT Field Trip

LR Locker Room

PE Playground/PE

SG School Grounds/Commons Area

BR Bus Ramp

CA Cafeteria

GY Gym

MC Media Center

PK Parking Lot

ST Stadium

Participants involved in incident (check one):

*input in ITYPE field on A24

S- Student

N- Non-student

B- Both student and non-student

U- Unknown

Prior action taken before referral (check one):

1- Conference with pupil

2- Referred to Counselor

3- Placed pupil in detention

4- Other action _________________________________

5- Re-teach expectations

6- Parental contact ____________________________________________ (date)

Phone

Letter

Conference

Possible motivation (check one):

1- Avoid Adult

2- Avoid Task/Activities

3- Obtain Adult Attention

4- Obtain Peer Attention

5- Avoid Peers

6- Obtain Items/Activities

7- Don’t Know

8- Other: ______________________________

Reported by (check one): Staff ID #s should be used. Persons without staff ID #s should use the following codes:

980 Area Manager (Trans)

977 Campus Aide

966 Custodian

973 Other

979 Security

975 Asst. Principal

962 Classroom Aide

976 Dean

969 Parent/Guardian

970 Student

978 Bus Attendant

964 Clerical

967 Food Service Staff

974 Principal

971 Sub Teacher

963 Bus Driver

965 Crossing Guard

968 Law Enforcement Officer

972 School Volunteer

Security Initials________________

Reported by (signature): __________________ Print Name: ___________________ Date: _______ Area Manager Initials: _____

Administrative Use Only

(Required)

Date received or date stamped by clerk:__________________________ Date Action Taken:________________________________

Action by Administration

Incident Description Code: ____________________________

Discipline Response/Action Code(s): __________________________

(see back of form for codes)

If suspended: (check one)

out of school

in- school

bus, for ________ days beginning ____________through _____________

(beginning date)

(Last day of suspension)

CONTACT WITH:

__________________________________________phone #_______________time _______ email ___________________________________

If parent conference was requested, give date and time of conference

: ________________________________________________________________

COMMENTS:______________________________________________________________________________________________________

Other data (check if appropriate):

Alcohol Related

Marijuana/hashish/other cannabinoids

Other Illicit Drugs

Hate Related

 Harassment /Bullying related: reason suspected__________________________________________________________

Gang related

Injury Related:

A - More Serious

B – Less Serious

Z – No serious bodily injury involved

Weapons description:

F-Firearm, Other

H-Handgun

K- Knife

O- Other Weapon

 More than 1 weapon used

R- Rifle or Shotgun

U- Unknown Weapon

Reported to Police: ____________ Date, time and to whom reported: _______________________ Case # ___________________

(Required for level IV)

(initial)

Administrator Signature: ___________________________________Parent/Student signature:________________________________

Incident # _________________

MI # _________________

White: School Administrator

Canary: Administrator Returns to Bus Driver with Disposition Pink: Transportation Manager Gold: Bus Driver

TRA0040 Rev.11/11

Form Tra0040 - Bus Safety Referral

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