Katherne B.

Sutton Elementary School Office Referral

Student Name Grade Race Date Time Teacher HR Teacher

Incident Location (Circle One) Possible Motivation(s) Restroom Media Center Avoid Adult Bus Loading Area Office Avoid Peers Cafeteria Bus (#_____) Avoid Activities Classroom Playground Don't Know Hallway Other__________Get Adult Attention Gymnasium _______________Get Items Get Peer Attention Other__________________ Incident Type (Circle One) Inappropriate Language Dress Code Defiance/Disrespect Arson Dishonesty Fighting/Physical Aggression Harassment/Taunting Bomb Threat/False Alarm Disruption/Horseplay Use/Possession of Combustible Bullying Use/Posession of Tobacco Forgery Use/Possession of Drugs Theft Use/Possession of Alcohol Description of Incident

Others Involved None Peer Staff Teacher Substitute Unknown Other __________________________

Use/Possession of Weapon Threat/Intimidation Sexual Harassment Sexual Offense/Misconduct Disorderly Conduct Assault/Battery Vandalism Other:____________________________

Teacher Interventions (Circle all that apply) Student Conference Parent Conference Reteach Expectation Time Out Seating Change Loss of Privilege Letter/Call Home Number of Days ISS OSS Student will return to class on _____/______/________ Teacher Signature Parent Signature Admin Signature

OFFICE USE ONLY Administrative Time Out Student Conference Counselor Referral Student Contract OSS ISS Date Date Date