Tempe Union High School District Referral Form Page 2
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2TEMPE UNION HIGH SCHOOL DISTRICT
NOTICE OF DISCIPLINARY ACTION
STUDENT:
STUDENT ID:
PARENT/GUARDIAN:
DATE: ________TIME OF INCIDENT:
________________________________________
________
INCIDENT CODES
(Check all boxes that apply/circle the main infraction)
Academic Misconduct/Dishonesty
Attendance Policy Violation
Drug Violation
Tobacco Violation
001. Cheating
021. Leaving School Grounds w/out
026.
065.
Drug – Distribute or Share**
Tobacco – Distribute or Share*
002. Forgery
022. Tardy
027. Drug –Use or Possession**
066. Tobacco–Use or Possession*
003. Lying
023. Truancy
028. Drug – Sale**
067. Tobacco – Sale*
004. Plagiarism
024. Unexcused Absence
Sexual Offenses
Aggression
025. Other Attendance Violation
048. Harassment, Sexual*
Vandalism or Criminal Damage
005. Verbal Provocation
Harassment, Threatening, & Intimidating
049. Harassment, Sexual w/Contact*
068. Graffiti or Tagging
006. Minor Aggressive Act
029. Bullying
050. Indecent Exposure
069. Vandalism Personal Property
007. Disorderly Conduct
030. Harassment, Nonsexual
051. Pornography
070. Vandalism School Property
008. Recklessness
031. Hazing
052. Sexual Abuse**
009. Endangerment*
032. Threatening or Intimidating
053. Sexual Assault**
School Threat
010. Fighting*
Other Violations of School Policies
Technology, Improper Use
044. Bomb Threat**
011. Assault*
033. Combustible
054. Computer
045.
Chemical/Biological Threat**
012. Aggravated Assault**
034. Contraband
055. Network Infraction
046. Fire Alarm Misuse **
013. Kidnapping**
035. Defiance or Disrespect
056. Telecommunication Device
047. Other Threat: __________
014. Homicide**
036. Disruption
057. Other Technology
015. Other Aggression: _____
037. Dress Code Violation
Theft
Weapons & Dangerous Items
Alcohol Violation
038. Gambling
058. Petty Theft
071. Dangerous Items*
016. Distribution or Share**
039. Language, Inappropriate
059. Theft
072. Firearms*
0
017. Use or Possession**
040. Negative Group Affiliation
060. Burglary (1
Degree)**
073. Simulated Firearm
0
0
018. Sale**
041. Parking Lot Violation
061. Burglary (2
/3
Degree)*
074. Other Weapons:
Arson
042. Public Display of Affection
062. Extortion
_____________
019. Of a Structure or Property*
043. Other Violation of School Policies
063. Robbery
020. Of an Occupied Structure**
064. Armed Robbery**
ACTION TAKEN
(Check all boxes that apply)
Completed in One Day
Completed in One or More Days
Completed in One or More Days
Removal
Confiscation of Contraband
Behavior Contract
Restitution
Expulsion w/Services
Drug Test
Behavior Intervention Group: Anger
Saturday School
Expulsion w/out Services
Parent Conference
Behavior Intervention Group: Drug
Teen Court
Long Term w/Services
Parent Notification
Behavior Intervention Group: Other
Threat Assessment
Long Term w/out Services
Short Term w/Services
Referred to outside agency
Behavior Intervention Plan
Work Detail
Student Conference
Community Service
Within Due Process
Short Term w/out Services
Student Verbal Apology
Detention
Appeal Review
In School Suspension
Student Written Apology
Functional Behavioral Assessment
Disciplinary Hearing
Alternative Education Setting
Warning
Meeting with School Counselor
IEP Team Meeting
Reassignment to Different Class
Withdrawal from School
Peer Mediation
Manifestation Determination
Reassignment other SchoolTUHSD
Privileges Suspended
Placement Review Committee
Law Enforcement Contacted -
Board Review
Report No: _____________
PARENT CONTACT BY ADMINISTRATION
(Check all boxes that apply)
C Conference
L Letter
P Phone & Letter
T Telephone: Number Called _______________________
H Home Visit
E Email
S Student Conference
V Voice/Left Message
COMMENTS
DETENTION DATE
DURATION
SUSPENSION DATES
DURATION
RETURN TO SCHOOL
ADMINISTRATOR SIGNATURE_____________________________________ ADMINISTRATIVE ACTION DATE___________
Revised – 2/10/2012
*Violation reported to Arizona Department of Education (ADE)
** Reported to local law enforcement and ADE
White – Administration
Pink – Student
Yellow – Parent/Guardian
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