Below is an example of the form we use when a student needs to be referred for further concerns. The staff as a whole devised this form to allow for complete and accurate information from the educator standpoint and also to allow for the student to have thier due process in the matter. We find that the form works well for record keeping regarding the types of incidents as well as acting as a more official document that communicates to the student that they have raised the level of their behavior to require such a referral.
Madison Preparatory High School
DISCIPLINARY REFERRAL
Student name: _____________________________________ Date: ________________
Time of occurrence: __________________
Parent contact: Date: ________
Student Conduct:
______ Insubordination
______ Swearing at a staff member
______ Disruptive behavior
______ Inappropriate behavior
Is the behavior: Chronic_______ 1st Time _____
If chronic, describe previous action taken: ____________________________
_________________________________________________________________
Staff Signature _____________________________________
Student account of incident: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Consequence: _________________________________________________________________
“I understand the consequences for my behavior choice and I am aware of the consequences in the future should my behavior continue.”
Student Signature ___________________________________
Principal Signature __________________________________
DISCIPLINARY REFERRAL
Student name: _____________________________________ Date: ________________
Time of occurrence: __________________
Parent contact: Date: ________
Student Conduct:
______ Insubordination
______ Swearing at a staff member
______ Disruptive behavior
______ Inappropriate behavior
Is the behavior: Chronic_______ 1st Time _____
If chronic, describe previous action taken: ____________________________
_________________________________________________________________
Staff Signature _____________________________________
Student account of incident: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Consequence: _________________________________________________________________
“I understand the consequences for my behavior choice and I am aware of the consequences in the future should my behavior continue.”
Student Signature ___________________________________
Principal Signature __________________________________