Katherne B.

Sutton Elementary School Classroom Referral

Dear Parents: Your child has violated the KBSES student behavior plan by not following the expectation(s) and rules(s) described below. We appreciate your immediate help in resolving this issue. While this is not an office referral form, continuous violations of school expectations and rules could result in an office referral. Student Name Grade Race Date Time Teacher HR Teacher

BE RESPECTFUL
Incident Location (Circle One)
Restroom Bus Ramp Cafeteria Classroom Hallway Gymnasium Media Center Office Bus (#_____) Playground Other:________ ______________

EXPECTATION VIOLATED: BE RESPONSIBLE

Possible Motivation (Circle One)
Avoid Adult Avoid Peers Avoid Activities Get Adult Attention Get Items Get Peer Attention Other:______________________ Horseplay Teasing/Taunting Disruption Bullying Dishonesty

BE SAFE
Incident Type (Circle One)
Dress Code Property Damage Forgery/Theft

Inappropriate Language Defiance/Disrespect

Description of Incident

Student Conference Reteach Expectation Seating Change Letter/Call Home Teacher Signature Parent Signature Admin Signature

Teacher Interventions (Circle all that apply) Parent Conference Counselor Referral Time Out Student Contract Loss of Privilege Other _______________________________________ Peer Mediation Date Date Date

Parent Comments: