Trenton Public Schools Referral Form

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Trenton   P ublic   S chools   R eferral   F orm
 
Name   _ _____________________           S ection   _ ____________           S tudent   I D   _ ________________  
Referring   S taff   _ ______________           D ate   _ ______________             L ocation   _ __________________  
School   _ ____________________  
 
Repeated   M inor   I nfractions  
 
Major   I nfractions  
(3   i nfractions   n eeded   t o   s ubmit   r eferral)  
 
(1   o r   m ore   n eeded   t o   s ubmit   r eferral)  
Repeated   I nfractions   C ausing   t his   R eferral  
 
Infraction  
Date  
Check   A ll   T hat   A pply   t o   T his   R eferral  
 
 
_____Fighting/Physical   A ggression  
 
  _ ____Blatant   D isrespect  
 
 
  _ ____Physical   A ssault  
 
  _ ____Terroristic   T hreats  
  _ ____Inapp.   S exual   B ehavior/Contact  
 
 
_____Indecent   E xposure  
 
_____Inciting   a   R iot  
 
_____Starting   a   F ire/Arson  
Prior   B ehavior   I nterventions   b y   S taff  
_____Harassment/Bullying  
Action   T aken  
Date  
_____Vandalism  
_____Forgery/Theft  
Polite   V erbal   R e-­‐direction  
 
_____Weapons   P ossession/Use  
 
_____Combustibles   P ossession/Use  
Seating   A ssignment   C hange  
 
_____Electronics   A buse  
 
_____Extortion  
Student   C onference  
 
_____Tobacco/Drug/Alcohol  
 
 
                        P ossession/Use
Student   s ent   t o   " Buddy   C lassroom"  
 
 
 
Teacher   D etention  
 
Administrative   A ctions  
 
(For   A dministration   O nly)  
 
Action   T aken  
Date  
Mandatory   P arent   C ontact  
Student   C onference  
 
Date   &   t ime   o f   p arent  
 
contact.  
Parent   C onference  
 
 
Peer   M ediation  
 
Who   w as   c ontacted?  
 
Guidance  
 
(Name   &   r elationship   t o  
student)  
Central   D etention  
 
What   p hone   #   o r   e mail  
 
ISS   ( Include   #   o f   D ays)  
 
address   w as   u sed?  
 
OSS   ( Include   #   o f   D ays)  
 
 
Other   ( Explain)  
 
Comments   ( Use   b ack   f or   a dditional   s pace)  
 
 
 
 
 
 
 
 
 
 
Administrator's     S ignature:  
 
_______________________________  
 
Entered   i nto   P ower   S chool   o n   ( Date):  
 
_______________________________  
 

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