Swis Office Discipline Referral Form

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Example A (Comprehensive)
SWIS Office Discipline Referral Form
Student __________________________ Grade ______ Staff
_______________________
Date
________ Time _______
Location
 Classroom
 Cafeteria
Restroom
 Library
A B C
Hallway
 Bus  Loading Zone
Common areas
 Special Event/Field Trip
 East  West
 Playground
 Gym
Other: _____________________________________________
Problem Behaviors Circle the most intrusive. Check one to three secondary behaviors if applicable.
MINOR
MAJOR
 Defiance/ disrespect/
 Defiance/ insubordination/
 Bullying
 Tobacco
non-compliance
non-compliance
 Fighting
 Drugs
 Disruption
 Disrespect
 Inappropriate location/
Weapons
out of bounds area
Knife : < 6”
 Physical contact
 Physical aggression
Knife : > 6”
 Tardy
 Disruption
 Truancy
 gun
 Inappropriate lang.
 Abusive lang./ inappr.
 Forgery/ theft/
 other: __________
lang./ profanity
plagiarism
 Property misuse
 Dress code
 Tardy
 Technology violation
 Technology
 Skipping
 Property damage
 Gang Display
 Other:
Harassment
 Lying/ cheating
 Bomb threat/
__________________
false alarm
 disability  race
 Dress code
 ethnicity  religion
 Inappropriate display of
Arson
 gender
 sexual
affection
 physical
 other
 Other: ____________________________________________
Possible Motivation
 Obtain Peer Attention
 Obtain Items/ activities
 Obtain Adult Attention
 Other
 Avoid Peer Attention
 Avoid Tasks/ activities
 Avoid Adult Attention
 Unknown
Others involved:
 No One  Peers  Teacher  Staff
 Substitute  Unknown
Other: _______________________
Restraint/ Seclusion:
 None
 Restraint
 Seclusion
 Restraint & Seclusion
Action(s) Taken Circle the most severe. Check one to three secondary behaviors, if applicable.
 Time out/ detention
 Out-of-sch. Susp. ____ days
 Additional attendance
 Expulsion ____ days
 Confer. w/ student
 Parent contact
 Bus suspension
 Alternative Placement
 In-sch. susp. ____ days  Time in office
 Restitution
 Action Pending
 Loss of privileges
 Individual instruction
 Community service
 Other: ______________
Notes

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