North Elementary School – Disciplinary Referral – Level 3/4

Name: ______Date: ______Time: ______

Teacher: ______Grade: 3 4 5 Referring Staff: ______

Location:  Bathroom  Bus  Cafeteria  Classroom  Hallway  Media  Playground  Other ______

Problem Behavior / Possible Motivation / Consequences
Circle: Minor Major
  Abusive language
  Defiance
  Disruption
  Fighting/ Physical aggression
  Harassment/ Bullying
  Inappropriate language
  Non-compliance
  Physical contact
  Property misuse
  Other ______
/   Obtain peer attention
  Obtain adult attention
  Obtain items/activities
  Avoid Peer(s)
  Avoid Adult
  Avoid task or activity
  Don’t know
  Other ______/   Conference with student
  Individualized instruction
  In-school suspension ( _____ hours/ days)
  Loss of privilege
  Out of school suspension ( _____ days)
  Parent Contact ______
  Restitution
  Social Worker
  Time in office (Stop and Think)
  Other ______

Others involved in incident:  None  Peers  Staff  Teacher  Unknown  Other

Comments:

Administrative Signature: ______Date: ______
Follow up Agreement

1. Which Respect was not followed? (Circle)

Myself Others Property

2. What did you want?

 I wanted attention from others  I wanted to be in control of the situation  I wanted revenge

 I wanted to challenge adult(s)  I wanted to avoid doing my work  I wanted to be sent home

 I wanted to cause problems because I feel miserable inside

 I wanted to cause others problems because they don’t like me

 I wanted ______

3. Did you get what you wanted?  yes  no

4. What will you do differently next time?

I will respect ______by .

5. Student signature: ______Date: ______

6.  Parent/ Guardian signature(s): ______