Read SWISTM OFFICE DISCIPLINE REFERRAL FORM text version

HAWKINS COUNTY MIDDLE/ HIGH SCHOOL OFFICE DISCIPLINE REFERRAL FORM

............................................................................................................................................. Student _____________________________________ Referring Staff ______________________________ Grade Level ______________ Incident Date _________________ Incident Time _________________ ............................................................................................................................................. Location Classroom Library Stadium/Athletic Facilities Playground Bus Loading Zone Office Commons Area/Cafeteria Parking Lot Locker room Hallway Bus Outside of Building Bathroom Special Event/Assembly/Field Trip (code as Other in SWIS) Gym Off-campus Unknown ............................................................................................................................................. Problem Behavior Abusive/inappropriate Property damage/vandalism Illegal walkout of class (code as language Forgery/theft Arson in SWIS) Fighting/physical aggression Dress code violation Use/possession of weapons Disrespect/Defiance/non Technology violation Failure to do assigned discipline compliance/insubordination Inappropriate public displays of (code as Other in SWIS) Lying /cheating affection Electronic devices (code as Harassment/bullying Inappropriate school location Unknown in SWIS) Multiple rule violations (code Use/possession of tobacco Gang Related activity as Disruption in SWIS) Use/possession of alcohol Tardy (above set limit) Use/possession of drugs Skip class/truancy ............................................................................................................................................. Possible Motivation Obtain peer attention Avoid peer(s) Obtain adult attention Avoid adults(s) Obtain items/activities Other Avoid tasks/activities Unknown motivation ............................................................................................................................................. Others Involved None Peers Staff Teacher Substitute Unknown Other ............................................................................................................................................. Teacher Comments. Please provide details of problem behavior including classroom management strategies used if applicable.

Student Response and Signature _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ....................................................................................................................................... Administrative Decision Time in office Theme/writing assignment Alternative School (code as Loss of privileges (code as Individualized Unknown Admin. Decision Conference with student Instruction in SWIS) in SWIS) Parent contact Bus suspension Extra Info 1. (Juvenille Court Detention AM PM Lunch In-school suspension referral) Restitution Out-of-school suspension Extra Info 2. (Harassment) Expulsion ability, racial, gender, religious, Other Admin. Decision sexual, other ............................................................................................................................................. Administrator Comments ........................................................................................................................................................................................... Administrator signature: __________________________Date seen_______________Time left office: _________

White-Office, Blue-Home, Yellow-SWIS/STAR data, Pink-Referring Staff after student seen

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SWISTM OFFICE DISCIPLINE REFERRAL FORM

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SWISTM OFFICE DISCIPLINE REFERRAL FORM
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