SOAR TO SUCCESS
Office Discipline Referral Form
Name: ______Grade: _____ Date: ______
Referring Person: ______Time: ______
Others involved: no one peers teacher staff substitute unknown
Expectation Violated: BE SAFE BE RESPECTFUL BE RESPONSIBLE
Issue of Concern Location Possible Motivation
Major Problem Behaviors
Fighting/Aggressive Behavior Playground Attention from peer(s)
Bullying/Harassment Cafeteria Attention from adult(s)
Chronic Minor Infractions 3-MIR Passing area Avoid peer(s)
Drugs/Alcohol/Weapons Bathroom Avoid adult(s)
Fighting Classroom Avoid work
Abusive Language Other ______ Obtain item(s)
Major Dishonesty Don’t know
Excessive Sleeping Other ______
Theft
Leaving Campus/Runners
Defiance
Lying/Cheating
Failure to Follow School Rules
Disrespect
Minor Problem Behaviors
Disruptive Sleeping Stealing
Dress Code Minor dishonesty Other______
Electronic Device Throwing
Physical Contact Disrespect
Inappropriate Language Physical contact
Defiance Property Misuse
What happened?______
______
______
Consequences
Lose recess Lose other privilege ______On Campus Community Service
Conference In-school suspension Refocus/Reflection Room
Parent contact Out-of-school suspension Level 1 – Days ______
Follow up agreement ABIL Other______
Follow up Agreement
Name: ______Date: ______
1. What rule(s) did you break? (Circle)
Be Safe Be Respectful Be Responsible
2. What did you want?
I wanted attention from others I wanted to be in control of the situation
I wanted to challenge adult(s) I wanted to avoid doing my work
I wanted to be sent home I wanted revenge
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 be… ______
5. Student signature: ______
6. Adult signature(s): ______