Safe Seat Self-Assessment

Name________________________
1.

2.

Date______________

Which school expectation did you break? Circle it.

Show Respect

Observe Safety

Accept Responsibility

Resolve Conflict

Why did you break the expectation? Circle one or

write it.

I didnt want
to do my work.

I wanted someones attention.

Other: ______________
_____________________

3.How were you feeling? Circle one picture.

Angry

Happy

Sad

Confused

Silly

4.Tell what happened and what you did.

________________________________________________________
________________________________________________________
________________________________________________________
5.Tell what you could do next time this happens.
To make better choices, I could _________________________
________________________________________________________
________________________________________________________
Parent Signature _________________________ Date _________
Please sign and return to school the next day.

This form was given by ___________________. Time?

_________

Parent Signature _________________________ Date _________

Please sign and return to school the next day.