Ray Street Student Discipline Referral

Student Name: / Date of Incident: Click here to enter a date. / Time:
Referring Staff: / Grade: Choose an item.

Teacher InterventionDateTeacher InterventionDate

Student/Teacher Warn/ConfClick here to enter a date.Time OutClick here to enter a date.

Parent/Teacher Phone/ConfClick here to enter a date.Refer to GuidanceClick here to enter a date.

Teacher DetentionClick here to enter a date.Other: Click here to enter a date.

Misbehavior Description:

Board Violations

Bullying

/
Falsifying Note
/
Other
/
Smoking
Bus Disturbance / Fight – Stu/Other / Damaging Property / Stealing
Cheating / Fight – Stu/Staff / Over the Counter Drugs Use Pos Dist / Tardy to Class
Chewing (Tobacco) / Fight – Stu/Stu / Personal Telecommunication Device / Excessive Tardies
Dangerous Instrument / Harassment (Board) / Present While Suspended / Threatening Staff
Disruptive Behavior
/ Inappropriate Sexual Behavior / Violation Tech Policy /
Tobacco – Other
Peer Conflict – Verbal / Leaving Campus / Profanity or Vulgarity / Electronic Cigarette
Physical Aggression /
Missed Detention
/ Skipping Class / Truancy
Dress Code Violation /
Gang Activity
/ Skipping School / Verbal Abuse
Fail to Obey Staff /
Disrespect (Teacher or Student)
/ Out of Restricted Area
Drug or Alcohol

Law Violations (Law Enforcement MUST be called) Possession/Distribution

Arson
/ Disorderly Conduct / Loitering / Sexual Assault / Poss / Dis
1st Degree Assault /
Driving Under Influence
/ Motor Vehicle Theft / Statutory Rape / Alcohol
2nd Degree Assault / Embezzlement / Other / Stolen Property / Amphetamines
3rd Degree Assault / Forcible Rape / Drug Paraphernalia / Terroristic Threat / Barbiturates
4th Degree Assault / Forgery & Counterfeiting / Extortion / Vandalism / Cocaine/Crack
Bomb Threat / Fraud / Harassment (Law) / Weapon – Handgun / Hallucinogenic
Burglary / Gambling / Look-Alike Toy/Weapon / Weapon – Oth.Firearm / Heroin
Chemical/Bio/Nuclear / Indecent Exposure / Robbery / Weapon - Other / Marijuana
Criminal Homicide / Larceny/Theft / Weapon – Rifle / Other Drug

Administrative Action

Conference-Phone/Parent/Guardian / None / Schedule Change /
Out of School Suspension
Conference-Principal / Refer to Counselor / School Privilege Denied / Law Only
Conference-Principal/Teacher / Refer to Student Assistance Team / Special Assignment / Transfer
Conference-Prin/Student/Parent / I.S..S.. Partial Day / Expelled, Services / Warning
Conference-Prin/Student/Teacher / I.S.S.. Day(s) /
Expelled, No Services
/ Withdrawn from School
Pending Action / I.S.S.. Lunch Detention / / Written Warning
Start Date: Click here to enter a date. / Days Suspended: Choose an item.
End Date: Click here to enter a date. / Date Student May Return to School: Click here to enter a date.
Administrator:
Administrative Action:
Parent Signature:______Date:______
Parent Comments: ______
Data Entered into PowerSchool ______by ______