Student Referral Form
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Items denoted with a red asterisk
*
are required.
*
Student Name
*
Staff Email
*
Date
*
Period
Teacher Detention
Teacher Detention
(Date Assigned)
Level One Behaviors
Cheating
Cutting Teacher Detention
Defiance/Disrespect
Dishonesty
Disruption
Dress Code Violation (minor)
Food and Drink Violation
Inappropriate Language
Physical Contact/Aggression
Property Misuse
Public Display of Affection
Tardy to Class
Technology Violation
Student engages in any other problem behavior that does not fall within the above categories
Level Two Behaviors
Repeatedly Cutting Detention
Expulsion from class or unauthorized departure from class
Cutting Class
Dress Code Violation (Major)
Possession of electronic devices-unauthorized radios, IPods, cell phones, and all other inappropriate items are not allowed in school
Wearing or possession of bags, bookbags, large purses, or backpacks to their classes.
Cheating/Plagiarism/Dishonesty
Improper care or loss of school textbooks and library books (school property)
Aggressive Behavior
Obscene Language
Level Three Behaviors
Disorderly Conduct (serious class disruption)
Destruction or Defacing of School Property/Vandalism
Stealing/Larceny
Harrassment, taunting, ridiculing, hazing, bullying or any display or inappropriate behavior to other students
Forging, falsifying, altering or illegal possession of school reports or records
Gross insubordination or disrespect to or about a staff member
Leaving School Grounds
Throwing of objects in a manner which could cause harm to person and/or personal property to others
Smoking
Trespassing
Level Four Behaviors
Assault of a Staff Member
Implied or stated threats to a staff member
Possession of explosives/Combustibles
Possession/distribution of controlled substances with intent to sell
Under the influence of controlled substances
Student fighting, assaulting, or threating another student
Tampering with fire fighting equipment or other communication systems
Bomb threats/false alarms
Gang Activity
Extortion
Arson
Breaking and Entering
Possession of Weapons
*
Possible Motivation
Obtain Peer Attention
Obtain Adult Attention
Obtain Items/Activities
Avoid Tasks/Activities
Avoid Peers
Avoid Adults
Don't Know/Unclear
Other
Describe Other Motivation
*
Describe Incident
Please provide as much detail as possible.
*
Previous Interventions
Warning
Conference with Student
Changed Seating
Sent to Office
None
Teacher Detention
Parent Contact
Other
Describe Other
Teacher Detention Dates
Parent Contact (Date & Time of Conversation(s))
