Meduley Catholic College - Responsible Thinking Room (T4) Referral Form Student's Name . Date . . Time .. © Not following instructions after several warnings. © Disrupting the learning of others in the class with talking or annoying behaviour, © Being disrespectful and talking back to the teacher. © Continued inappropriate use of laptop or technology after several warnings. © Using phone and refusing to hand over phone after clear request. © Swearing or inappropriate language. © Graffiti or vandalism. © Bullying or violent behaviour. © Other (Please specify) Other relevant information ‘TeacherDaily Personal Management Record Name: [ Period HR 1 2 3 4 5 6 Subject ‘1. Punctual to class Yes /No Yes /No ‘Yes /No ‘yes / No Yes /No ‘Yes / No. Yes / No | 2. Completes set | tasks ‘ (G,S, U) 3. Accepts correction without objecting | Yes /No | Yes /No_| Yes/No | Yes /No yes /No | Yes/No | Yes /No | instructions yes /No| ves /No | Yes/No | Yes/No | Yes/No | Yes/No_| Yes /No |S." Uses appropriate Yes /No Yes /No Yes / No Yes / No Yes {No Yes /No- Yes / No Language at all, times 6. Showed respect for others (G,5,U) | | Teacher's | Signature/Comment | Parent's Signature Homeroom Teacher's Signature Year Co-ordinator’s SignatureMcAuley Catholic College - Responsible Thinking Room Re-entry to Class Student .... reer .. Homeroom... ‘Teacher ..... ‘Subject Student's statement to teacher..... Classroom Teacher’s Comments/additional requirements ... Student's Signature ...ssscssssscssseeeenesseesseees Teacher's signature RTR (T4) Supervisor'sHow Are You Feeling Today?