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Carlock Office Discipline Referral Form
Name: _________________________ Grade: _____ Date: _____
Referring Person: ________________________Time: ________
Others involved: no one peers teacher staff substitute unknown
Issue of Concern Location Possible Motivation
Major Problem Behaviors Classroom Attention from peer(s)
Inappropriate Language Playground Attention from adult(s)
Fighting/Physical Aggression Lunchroom Avoid peers(s)
Harassment Hallway Avoid adult(s)
Threatening/bullying Bathroom Avoid work
Lying/cheating Bus Area Obtain item(s)
Vandalism Special event Other______________
Dress code Gym/Music/Art/IMC Don’t know
Other _____________ Other _____________
Minor Problem Behaviors
Inappropriate Language
Minor Disruption
Property Misuse
Defiance/Disrespect
Tardy
Other _____________
Staff Comments/Narrative: ______________________________________________
_____________________________________________________________
Consequences
Lose recess Lose other privilege ___________________________
Conference In-school suspension
Parent contacted Out-of-school suspension
Follow up agreement
Follow up Agreement
Name: __________________________ Date: __________________
1. What rule(s) did you break? (Circle)
Be Safe Be Respectful Be Responsible
2. What did you want?
I wanted attention from others I wanted to be in control of the situation
I wanted to challenge adult(s) I wanted to avoid doing my work
I wanted to be sent home I wanted revenge
I wanted to cause others problems because they don’t like me
I wanted _________________________________________
3. Did you get what you wanted? yes no
4. What will you do differently next time?
I will be _____________________________ by _________________________
5. Student signature: __________________________________________