Elementary School Documentation Form

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SOUTH FREDERICK ELEMENTARY DOCUMENTATION FORM
Student:
Documenting Person:
Time:
Date:
Grade:
Homeroom:
Staff Members Present:
LOCATION:
STUDENT:
PREVIOUS ACTIONS:
SCHOOL RULE BROKEN:
Cafeteria
Was asked to do something
Verbal redirection
q
q
q
Keep hands feet and objects to
q
Hallway
Resisted transition
Warning
q
q
q
self
Classroom
Could not get desired item/activity
Time-out in room
q
q
q
*
person
* property
Playground
Was emotional or upset
(duration__________)
q
q
Speak respectfully
q
Outside
Was provoked by another student
Time out in another room
q
q
q
Use materials/equipment safely
q
Bathroom
Was asked to work independently
(duration__________)
q
q
Follow directions
q
Media Center
Was asked to work in a group/pair
Problem solving
q
q
q
Show listening
q
Computer Lab
Other
Separation of students
q
q
q
Gymnasium
Additional task/assignment given
q
q
____________________________
Special Activity (specify)
Loss time on recess/activity
q
q
Loss access to items
q
____________________________
DESCRIPTION OF BEHAVIORS
ACTIONS TAKEN
Parent Contact by Documenting Person Date _________ Time__________
Student Assignment:
Date
Follow up:
Date
Face to Face Conversation
Apology Letter *
q
Telephone Conversation (Phone #) _____________________________
Problem Solving
Detention with (name):
q
Left Message at (Phone #) __________________________________
Plan *
q
________________________
Summary of Conversation
Lunch *
Recess *
Contract with:
AM *
PM *
Teacher *
Student Support *
Other ___________________
Parent *
________________________
Called Parent:
NDW *
Date __________
Time __________
Refer to __________________
Reviewed By: (Initials) _________
Title:
Principal
Assistant Principal
Guidance Counselor
Student Support Teacher
*
*
*
*
Parent/Guardian’s Signature
Date:
Student’s Signature

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