Cotton Center Independent School District Code Of Conduct Violation Referral Form
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1COTTON CENTER INDEPENDENT SCHOOL DISTRICT
CODE OF CONDUCT VIOLATION REFERRAL FORM
Student Name: _______________________________ Date of Incident: ________________________
Teacher: ____________________________________ Time of Day: ___________________________
Detailed Explanation of Misconduct: ______________________________________________________
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_____________________________________________________________________________________
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_____________________________________________________________________________________
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Reported by: ______________________________
Date: _________________________________
PRIOR ACTION TAKEN BY TEACHER
( ) Assigned different seat
( ) Parent conference
( ) Student conference
( ) Behavior modification plan
( ) Phone contact to parent
( ) Time out
( ) Detention
( ) Progress report sent home
( ) Verbal correction
nd
( ) 2
Detention
( ) Referred to counselor
( ) Other _____________________
( ) Loss of Privileges/recess
( ) Referred to principal
___________________________
ACTION TAKEN BY ADMINISTRATOR
( ) Apology
( ) Letter sent home
( ) Out of school suspension OSS
( ) Citation issued
( ) Parents contacted
( ) In-school suspension ISS
( ) Corporal punishment
( ) Self-imposed detention/report ( ) Short Term DAEP
( ) Counseled/Warned
( ) Detention
( ) Long Term DAEP
( ) Saturday School
( ) Emergency Removal
( ) Other _____________________
Administrator’s Signature: ______________________________________________ Date: ___________________
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