Be Respectful, Be Responsible, Be Kind & Be Safe 1.

DATE & LOCATION

Inside Location: Classroom Hallway Media Center Gym/Lunchroom Restroom Other(Describe) MON TUES WED THURS FRI Date:___________Time:___________ Outside Location: Playground By Front Doors Line Up Basketball Court Student:_______________________________ Grade: PreK K 1 2 3 4 5 6 7 8

Reported by:___________________________ Send Copy to Teacher____________________

MINOR(Staff member determines consequence) MAJOR(Administrator determines consequence)

2. NATURE OF INCIDENT OR BEHAVIOR

Behavior
Tardy Disruptive Off-Task Missing Work Defiant Other(Describe) Unsafe Touching/Fighting Language/Gestures Harassment/Teasing Bullying Vandalism

Possible Motivation
Obtain PEER attention Obtain ADULT attention Obtain ITEMS or ACTIVITIES Avoid PEER attention Avoid ADULT attention Dont Know Other(Describe)

Others Involved
None Peers Staff Substitute Unknown Others

3. CONSEQUENCES GIVEN
By Staff Informal Discussion Formal Discussion Loss of Privilege Contract Parent Note Parent Call Parent Conference None(informational report only) Other(describe) 4. PARENT FOLLOW-UP

Administrator Follow-up Requested Administrator Follow-up NOT Requested By Administrator Discussion with Student Loss of Privilege Parent Note Parent Call Parent Conference Suspension Time in Office Referral To Counselor Other(describe
Parent Signature NOT Requested Parent Signature Requested

(Return copy to ________________________(TEACHER)______________________(DATE) Please discuss this incident/behavior with your child, sign and return a copy of this to school by the date above. Parent Signature__________________________________________________________Date__________________________ Parent Contacted Via Phone Email Note