Office Discipline Referral (ODR)

2011-12 Lawrence County Schools

Office Discipline Referral (ODR)

Student Name: ______Grade: ______Referring Staff: ______

Day: M T W TH F Date: ______Time: ______Homeroom Teacher: ______

School’s Guidelines for Success not followed:

____Be Responsible ____Be Respectful ____Be Ready to Learn

Previous Interventions: ____ Student and/or parent conference ____ Behavior Plan ____Other:______

Minor Problem Behaviors / Major Problem Behavior / Possible Motivation
____ Defiance/disrespect/non-compliance
____ Disruption
____ Dress Code Violation
____ Inappropriate Language
____ Physical contact/aggression
____ Property misuse
____ Tardy
____ Technology Violation
____ Other: ______
Dates and/or consequences of previous minor incidents:
Location of Incident
____ Bus
____ Cafeteria
____ Campus Grounds
____ Classroom
____ Gym
____ Hall/Locker
____ Library
____ Off Campus
____ Playground
____ Restroom
____ Stairway
____ Other: ______/ ____ Abuse of School Personnel
____ Abuse/Inappropriate Lang./Profanity
____ Academic Cheating
____ Arson
____ Bomb threat/False Alarm
____ Bus Discipline
____ Cell phone violation
____ Defiance/Disrespect/Non-compliance
____ Disruption
____ Dress Code Violation
____ Driving or parking violation
____ Excessive Tardiness
____ Failure to attend detention
____ Failure to complete assignments
____ Fighting/Physical aggression
____ Forgery/Theft
____Habitual infractions (3 or more Minors)
____ Harassment/Teasing/Taunting/Bullying
____ Inappropriate Display of Affection
____ Inappropriate Location/Out of area
____ Lying/Cheating
____ Plagiarism
____ Property Damage/Vandalism
____ Skipping class
____ Technology violation
____ Threatening others
____ Use/Possession of Alcohol, Tobacco,
Drugs, Combustible Items (circle one)
____ Weapon
____ Other: ______/ ____ Avoid adults
____ Avoid embarrassment
____ Avoid peers
____ Avoid task/activity
____ Avoid work
____ Obtain adult attention
____ Obtain item/activity
____ Obtain peer attention
____ Unclear/unknown
____ Other: ______
Administrative Action
(To be completed by office staff)
______Bus suspension
______Community Service
______Conference with student
______Contact proper law
enforcement authorities
______Corporal punishment
______Expulsion
______Individualized Instruction
______In-school suspension
______Loss of privileges
______Out-of-school suspension
______Parent contact/conference
______Referral to ______
______Restitution
______Time in Office
______Time Out/Detention
______Other: ______
Days Suspended ______

Others involved: _____None ____Peers ____Staff ____Substitute ____Unknown ____Other: ______

Details of Behavior and/or Consequences:
______
______
______

Referring Staff Signature: ______Principal Signature: ______

Student Signature: ______Parent/Guardian Signature: ______