Dos Palos High School Referral Form

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Dos Palos High School
Referral Form
Student: _______________________________ Referring Staff:_________________________ Period:_______
Grade: ______ Date of Incident: ________________________Date of Referral: _________________________
Problem Behaviors (Check all that apply)
__ Un Prepared
__Fighting/Physical Aggression
__Un prepared for class
__Off Task
__Cheating/Plagiarism
__ Profanity
__ Harassment/Bullying
__Dress Code Violation
__Inapp. Display of Affection
__Electronics Violation
__Defiant/Disobedient
__Other: __________
Specific Information Regarding Incident:_________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Teacher Interventions
__Student Warning
__Parent Contact by Teacher
__ Seating Assignment Change
__Parent Conference with Teacher __Previous Referral to Office
__Other: __________________
Details:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Action Taken By Administration
__Conference with Student
__In School Suspension
__Campus Beautification
__Parent Contact
__Out of School Suspension __Behavior Contract
__Detention
__Counselor Referral
__Attendance Contract
__Step
__Counseling
__Other: ____________________
Details:____________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Signatures:
Referred By_____________________________________
Date_______________
Administrator___________________________________
Date_______________
Parent/Guardian_________________________________
Date_______________
(if applicable)

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