School Discipline Referral Form printable pdf download

Chicago Public Schools

School Name___________________________________________________________________________________________

Principal Name_________________________________________________________________________________________

SCHOOL DISCIPLINE REFERRAL FORM

(Mention only the name of the student involved)

Event Date___________________________Time___________________________Location__________________________

Reported By_________________________________________________________Position___________________________

Type of Occurrence (SCC Violation, Accident, Other)__________________________________________________________

First Occurrence

Second Occurrence

Third Occurrence

Fourth Occurrence

Last Name, First Name

Room/Division

Injury Occurred?

Yes

Provide a comprehensive narrative of the problem (identifying others as student 1, student 2, etc.; witness 1, witness 2, etc.).

May continue on reverse side if needed.

_____________________________________________________________________________________________________

Summary of background information and previous actions taken.

_____________________________________________________________________________________________________

Teacher Contact with Parent/Guardian: Date(s)_________________________Phone # Utilized________________________

Result of Contact (i.e., phone disconnected, message left, etc.)____________________________________________________

______________________________________________________________________________________________________

Staff Signature_______________________________________________ Date________________Time__________________

ADMINISTRATIVE USE ONLY

Administrator Signature______________________________________Date________________Time________________

Misconduct Report Initiated?

Yes

Number________________________________________

Incident Report Initiated?

Yes

Number________________________________________

Final Disposition of Referral_________________________________________________________________________

RETURN COPY OF COMPLETED FORM TO INITIATOR

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School Discipline Referral Form