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



    Other _____________

    Staff Comments/Narrative: ______________________________________________



    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: __________________________________________