Name: ________________

Date: __________________

Grade: ________________

Class: __________________

Scholar Reflection Sheet

1. Why were you sent to reflect?
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2. How are you feeling right now?
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3. Why are you feeling that way?
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4. What can you do next time so that you can stay in the classroom?
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5. What can you do so that you can successfully rejoin your class?
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Teacher Reflection Form (over)

Summer SHINE Teacher S.R.R. Reflection Form

Teacher Name: ________________________

Student Name: ________________________
Date of Meeting: ______________________
Time of Meeting: ______________________
Please describe the meeting you had with your scholar ( what was said, what was the outcome, what
strategies will be used with this student in the future to help prevent this situation from happening
again?)

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Additional support requested from the teacher:
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This form must be completed and submitted to Jernna DeNicola by 2:00 on the day the student
is in S.R.R.

The parent was contacted on ________________ (date) at ________________ (time)