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: __________________________________________