Expected Behaviors In Safe And Supportive Schools: Discipline Referral Form printable pdf download

Expected Behaviors in Safe and Supportive Schools: Discipline Referral Form

Person Originating the Referral: _________________________________________

INCIDENT INFORMATION

Date ___/___/_____

Time ___:___ am/pm

Number(s) involved ____

Serious Bodily Injury:  Yes No

Incident Category

 Tardiness Or Truancy

 Disrespectful/ Inappropriate Conduct



 Weapons

Aggressive Conduct

 Failure To Obey Rules/ Authority

 Legal Concerns



Illegal Drugs/ Substances

Location

 Athletic Field

 Bus

 Gym

 Playground

 Auditorium

 Cafeteria

 Hall/ Breeze Way

 Parking Lot

 Bathroom/ Restroom

 Classroom

 Locker Room

 Shop Area

 Bus Loading Zone

 Computer Lab

 Library

 Special Event/ Assembly/ Field Trip

 Bus Stop

 Commons/ Common Areas

 Office

 Stairwell

COMPLETE THE FOLLOWING INFORMATION FOR EACH PERSON INVOLVED IN THE INCIDENT

Use separate sheets for each person. All sheets completed for a single incident should be stapled together.

Person Number __

Role?  Peer  Staff  Student  Substitute  Other

Name: ________________________________

Behaviors Exhibited

You may indicate up to THREE behaviors for each person involved as follows:

P = Primary (Most Severe) Behavior S = Secondary Behavior A = Additional Behavior

____ Cheating

____ Insubordination

____ Larceny

____ Deceit

____ Leaving School Without Permission

____ Sexual Misconduct

____ Disruptive/Disrespectful Conduct

____ Physical Fight Without Injury

____ Threat of Injury/Assault Against An Employee

____ Failure to Serve Detention

____ Possession of Imitation Weapon

or A Student

____ Falsifying Identity

____ Possession of Knife not meeting Dangerous Weapon

____ Trespassing

____ Inappropriate Appearance

Definition (West Virginia Code §61‐7‐2)

____ Harassment/Bullying/Intimidation

____ Inappropriate Display of Affection

____ Profane Language/ Obscene Gesture/ Indecent Act

____ Imitation Drugs: Possession, Use, Distribution

____ Inappropriate Language

Toward An Employee or A Student

or Sale

____ Possession of Inappropriate Personal

____ Technology Misuse

____ Inhalant Abuse

Property

____ Battery Against a Student

____ Possession/Use of Substance Containing

____ Skipping Class

____ Defacing School Property/ Vandalism

Tobacco and/or Nicotine

____ Tardiness

____ False Fire Alarm

____ Battery Against a School Employee

____ Vehicle Parking Violation

____ Fraud/Forgery

____ Felony

____ Gang Related Activity

____ Gambling

____ Illegal Substance Related Behaviors

____ Habitual Violation of School Rules or

____ Hazing

____ Possession and/or Use of Dangerous Weapon

Policies

____ Improper or Negligent Operation of a Motor Vehicle

____ Involved as non‐offender, victim or target of

incident

Was Restraint Required for this Person?  Yes No

This offense reflects a need for intervention for which of the School and Community Social Skill Standards?

 Self-awareness and Self-management  Social-awareness and Interpersonal Skills Decision-making Skills and Responsible Behaviors

Comments:

Interventions

You may indicate up to TWO Interventions each person as follows: P = Primary Action S = Secondary Action

____ Administrator/student conference or

____ Referral to a tobacco cessation program

____ In‐school suspension

reprimand

____ Change in the student's class schedule

____ Law enforcement notification if warranted

____ Administrator and teacher‐

____ School service assignment

____ Removal of a student w/disability to Interim

parent/guardian conference

____ Confiscation of inappropriate item

Alternative Educational by school personnel

____ Academic sanctions

____ Revocation of privileges

____ Removal of a student w/ disability to Interim

____ Counseling referrals and conference to

____ Restitution/restoration

Alternative Educational by a WVDE Due

support staff or agencies

____ Detention – lunch

Process Hearing Officer

____ Daily/weekly progress reports

____ Detention ‐ before school

____ Removal of a student to an alternative

____ Behavioral contracts

____ Detention ‐ after school

education placement

____ Referral to IEP Team

____ Denial of participation in class and/or school activities

____ Out‐of‐school suspension

____ Referral to support staff/agencies for

____ Immediate exclusion by teacher from the classroom

____ Recommended Expulsion

counseling/other therapeutic services

____ Voluntary weekend detention

Primary: Start Date:

___/___/_____

End Date

___/___/_____

Secondary: Start Date:

___/___/_____ End Date

___/___/_____

Duration: _________ Days

Comments

Expected Behaviors In Safe And Supportive Schools: Discipline Referral Form

Related Articles

Related forms

Related Categories