Transcript Slide 1
The Office Referral Form Purpose is not to “nail” students Purpose is: to guide and document corrective actions taken by teacher to communicate with administration to generate data for the school level team to identify current behaviors, locations and other problematic patterns and to brainstorm school-level interventions SMALLEY SCHOOL OFFICE BEHAVIOR REFERRAL Location Student:__________________________________________ Date__________ ID # _________________ Grade: _______ Time: ______ Period: ____ Class: _____________________ Referring Staff _____________________________________ Minor Problem Behavior Situation is Remedied by Staff Offense 1 st 2 nd Current or Previous Action Taken by Staff for Minor Problem Behaviors 3 rd Date _______ _______ _______ Defiance/Disrespect Disruption Excessive talking Horseplay Inappropriate: display of affection language/gestures Lying, cheating Missed Detention Misused pass Misuse of property or electronics Tardy Tattling, teasing, name calling Other : _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ _______ Others Involved: None Staff Substitute Peers Teacher Other/Comments __ Bus __ Classroom #_____ __ Cafeteria __ Gym/ locker room __ Hallway _____ __ __ Library __ Off school grounds _______________________ Complete all that apply Major Infraction Requires Administrative Action Disciplinarian’s Decision for Major Infraction Date Student verbally corrected Student assigned different seat Teacher-student conference Teacher-student discipline Detention Other ______ ______ ______ ______ ______ Teacher-parent contact Phone Note Meeting Guidance counselor contact Student’s I.E.P. reviewed I&RS referral Referral to peer mediation Other: ______ ______ ______ ______ ______ ______ ______ ______ Comments: __Abusive/inappropriate interaction __Bomb threat/ false alarm __Bullying __Cutting class __Disruption __Fighting/physical aggression __Forgery/theft __Harassment __Inappropriate dress __Inappropriate sexual contact __Inappropriate use of: __communication device __school network or internet __Insubordination __Property damage/vandalism __Threat (written or verbal) __Use/possession of a weapon __Use/possession of an illegal drug or alcohol __Use/possession of combustibles __Use/possession of tobacco __Other: __Loss of privileges __Detention ___AM ___PM ___ 3 hour __Conference with student __Parent contact ___________________ __Suspension: In/ Out _____ hours / days __Community Service _____ hours / days __Referral to peer mediation __Police contact __Legal hearing request __Guidance contact __Change clothes __Send home __I&RS referral __Follow threat procedure __Other: Date ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ Comments: Action was towards: Student Comments: PLEASE ATTACH A DESCRIPTION OF THE INCIDENT IF NECESSARY Student Signature:_________________________ Parent Signature: __________________________ __ Offices _______ __ Boys/Girls room __ On school grounds Date: _____ Date: _____ Others Involved: ___ None ___ Staff ___ Substitute ___ Peers ___ Teacher ___ Other Staff Further Administrative Action Taken: Copy to staff member on ____ Form revision: 7/14/2005 Assistant Principal Signature:________________________ Date: ____ Principal Signature: ________________________________ Date: ____