SWIS Student Referral Form

Student: Referred By: Time: Date:

Grade: Homeroom: Staff Members Present: Recorded

LOCATION: (choose one)
q  Cafeteria
q  Hallway
q  Classroom
q  Playground
q  Outside, dismissal or arrival
q  Bathroom
q  Media Center
q  Computer Lab
q  Gymnasium
q  Office
q  Bus
q  Other ______
OTHERS INVOLVED: (choose one)
q  None
q  Peers
q  Staff
q  Teacher
q  Substitute
q  Unknown
q  Other ______/ STUDENT: (choose one)
q  Was asked to do something
q  Resisted transition
q  Could not get desired item/activity
q  Was emotional or upset
q  Was provoked by another student
q  Other ______
MOTIVATION (choose one)
q  Obtain peer attention
q  Obtain teacher attention
q  Obtain item/activity
q  Avoid work
q  Avoid peers
q  Avoid adult
q  Unclear/don’t know / MINOR BEHAVIOR (choose one)
q  Inappropriate language
q  Physical Contact
q  Defiant/Disrespectful/Non Compliant
q  Property Misuse
q  Disruption
q  Other ______
MAJOR BEHAVIOR (choose one)
q  Abusive/inappropriate language
q  Fighting
q  Physical Aggression
q  Insubordination
q  Student Threat
q  Major Disruption
q  Harassment/Discrimination
q  Property damage (school)
q  Property damage (others)
q  Vandalism
q  Theft
q  Other ______/
PREVIOUS ACTIONS
q  NOT APPLICABLE
q  Warning
q  Verbal redirection
q  Problem solving
q  Required to continue activity
q  Time-out in room (duration______)
q  Time out in another room
(duration______)
q  Separation of students
q  Additional task/assignment given
q  Loss time on recess/activity
q  Loss access to items
q  Parent phone call
q  Parent conference
Attach any relevant
Documentation Forms

DESCRIPTION OF INCIDENT

(A) Antecedent

(B) Behavior

(C) Consequence

ACTIONS TAKEN

Conference With:
Student *
Parent *
Unit Coordinator *
Asst. Principal *
Counselor *
Social Worker *
School Psychologist *
Pupil Personnel Member * /

Date

/ Referral to:
PPT *
Guidance *
Parent Coordinator *
IEP Team *
Community Agency *
Peer Mediation *
Conflict Resolution *
Other * ______/ Student Assignment:
Letter *
Written summary *
School assignment *
Call parent * / Behavior Interventions:
Social Skills Booster Group *
CICO (Check-In Check-Out) *
CnC (Check and Connect) *
Behavior Card *
FBA/BIP *
Behavior Contract *
Environmental Modifications *
Academic Modification *
Other * ______/ Administrative Actions:
Warning *
Letter of Probation *
Loss of Privilege *
Student Threat Assessment *
In-school Retention *
Suspension * (bus, out-of-school)
Student Threat Assessment *
Parent Conference *
Time in Office *
Other * ______/

Date(s)

COMMENTS:

Administrator’s Signature Date: Parent Requested Copy of Referral *