School Discipline Form

SCHOOL DISCIPLINE FORM

The form below is for use by any school personnel to document student misbehavior. It is suggested that it be kept in a student’s folder (for a limited time) to inform other personnel about this student. It is recommended that it be destroyed when the student leaves the school.

your school name here

STUDENT DISCIPLINE REFERRAL

School Administrator
School Counselor
Special Education Administrator/Counselor
Parent
All Grade Levels

GENERAL INFORMATION

Last Name: / First: / Grade: / Time of Incident:
Date of Incident: / Date of Referral:
Report Prepared by: / Title of Reporter: / Location of Infraction:

reason for referral (Check all that apply)

Unacceptable Language / Willful Refusal to Follow Directions or Instructions
Disruptive Horseplay / Disruption in: Cafeteria / Classroom / Hallway / Restroom / Outside
Fighting / Possession of a Controlled / Non-Controlled Substance (circle one)
Willful Disrespect to School Official / Oral Tobacco / Smoking (circle one)
Willful Damage to School Property / Chronic Tardiness
Willful Damage to Personal Property / Under Influence of Drugs / Alcohol – Law enforcement intervention
Skipping Class or Unauthorized Area / Possession of a Weapon – Law enforcement intervention
Bullying or Hazing / Dress Code Violation
Behavior Card Violation: ______/ Other Infraction: (Explain) ______
Description of Infraction:

prior action(s) taken by teacher

** Note: Parent must be contacted in regard to this INCIDENT BEFORE referral will be processed.

Behavior Card Deduction: Current point level: ______/ Parent Notification by Letter: Date(s)______
Previous Parental Notification(s) by Phone / Date/Time / Date/Time / Date/Time / Parental Notification on this Incident / Date/Time / Phone # / Name of Parent Contacted
Verbal Warning: Date(s) ______/ Conference with Student: Date(s):______
Silent Lunch: Date(s) ______/ In-Team / In-Grade Displacement: Date(s):______
Conference with Parents: Date(s)______/ After-School Detention: Date(s):______
Other Action(s):

administrative action

Consultation with Student in Office

AOG: Yes No

Warning Issued for Offense

Method: Verbal Written

Parent Notification Method

Phone | Phone #: ______

Date:______Time:______
Contact:______/

Copy of Referral

Letter

Student Delivery
1st Class
Certified Mail
/

In-School Suspension (ISS)

No. of Days: ______

Inclusive Dates: ______

Out-of-School Suspension (OSS)

No. of Days: ______

Inclusive Dates: ______

After-School Detention (ASD)

No. of Days: ______

Inclusive Dates: ______

Saturday School (SS)

Date: ______

NOTE: CC: Referral to SS Coordinator

Guidance Counselor Referral (GCR)

Name of Counselor: ______

NOTE: CC: Referral to Counselor

Compensation for Damages

Amt. of Payment: $ ______

Payment Due Date:

Campus Police Referral

Officer #: ______

NOTE: See C.O.C. for Requirements

Other Action (Explain): ______

Student Signature: ______Date:______

ADMINISTRATOR SIGNATURE: ______DATE: ______
PARENT SIGNATURE: ______DATE:______