DISCIPLINE REFERRAL FORM

Hollydale Elementary School

503-661-6226

Name ______Location

Date of Incident ______Time ______

Homeroom ______Grade: K 1 2 3 4 5

Referring Staff ______

Check all that apply. Circle the most prominent item under each heading.

Problem Behavior / Possible Motivation / Administrative Decision
Level I (Minor)
¨ Defiance/Disrespect
¨ Disruption
¨ Inappropriate language
¨ Lying/Cheating
¨ Physical contact
¨ Non-compliance
¨ Other ______
Level II (Major)
¨ Abusive language
¨ Fighting/Physical aggression
¨ Overt defiance
¨ Harassment/Bullying
¨ Significant Disruption
¨ Theft
¨ Weapon
¨ Other ______/ ¨ Obtain peer attention
¨ Obtain adult attention
¨ Obtain items/activities
¨ Avoid peer(s)
¨ Avoid adult
¨ Avoid task or activity
¨ Revenge
¨ Unclear
¨ Other ______/ ¨ Loss of privilege
¨ Time in office
¨ Conference with student
¨ Parent contact
¨ Form sent to parent
¨ Individualized instruction and/or Problem Solving
¨ Restitution/Community Service
¨ Out of school suspension
¨ Bus suspension
¨ Other ______

Others involved in incident: ¨ None ¨ Peers ¨ Staff ¨ Teacher

¨ Substitute ¨ Unknown ¨ Other ______

Referring Staff/Administrator Comments: ______

______

______

Administrative Signature ______Date ______

Student Signature ______Date ______

Parent Signature ______Date ______

Please sign and return the following school day.

White – Office Yellow – Parent Pink – Teacher

Date Sent ______
HOLLYDALE OFFICE REFERRAL DEFINITIONS

Adopted from SWIS™

Level I Problem Behavior / Definition
Inappropriate language / Low intensity instance of inappropriate language.
Physical Contact / Non-serious, but inappropriate physical contact.
Defiance/disrespect/
non-compliance / Brief or low-intensity failure to respond to adult requests.
Disruption / Low-intensity, but inappropriate disruption.
Other / Any other minor problem behaviors that do not fall within the above categories. Staff using this area will specify the problem behavior observed.
Level II Problem Behavior / Definition
Abusive language / Verbal messages that include swearing, name calling or use of words in an inappropriate way.
Fighting/Physical Aggression / Actions involving serious physical contact where injury may occur (e.g., hitting, punching, hitting with an object, kicking, hair pulling, scratching, etc.)
Overt defiance / Student does not respond to adult requests.
Harassment/Bullying / Student delivers disrespectful messages (verbal or gestural) to another person that includes threats and intimidation, unwanted physical contact, obscene gestures, pictures, or written notes. Disrespectful messages include negative comments based on race, religion, gender, age, and/or national origin; sustained or intense verbal attacks based on ethnic origin, disabilities or other personal matters.
Significant Disruption / High-intensity, inappropriate disruption.
Other / Problem behavior causing this referral and not listed above. Staff using this area will specify the problem behavior observed.
Locations / Definition
Restroom / Areas used by students for taking care of personal needs.
Bus area / The area used for bus loading and unloading
Cafeteria / The area used for breakfast and lunch.
Classroom / Classrooms used for instructional purposes
Commons / Areas shared by students and staff for specific activities.
Gym / Areas used for physical education activities.
Library / The area designated for research and study.
Playground / The outside area used for recess breaks.
Other / Location for referral occurs in a location that is not listed above. Staff using this area will specify the location for the problem.