Revised August 2011

SECONDARY STUDENT DISCIPLINE REPORT

One form per student
Students Name
Student ID #
Report of Incident:

Grade

School
Date of Infraction

Period of Infraction

Reporting Staff Member

Incident Location (Check One)
Cafeteria
Other Outdoor Area

Classroom

Hallway

Locker

Off Campus

Parking Lot

Restroom

School Bus

Stairwell

Other Indoor Area

STAFF ACTION BEFORE REFERRAL

Date

Date

Conference with student

Consulted administration

Consulted counselor

Mediation

Phone call home

Social Worker/Chemical Counselor

Detention with teacher

Followed class discipline procedure

Parent/Teacher conference

Consulted Case Manager

FOR OFFICE USE ONLY

REASON FOR REFERRAL Check Appropriate Incident Code
ACD Academic dishonesty
ALC Alcohol violation
CHE Chemical violation
DIS Disruptive behavior
DRE Inappropriate dress
FGY Forgery
GAM Gambling
HAR Harmful/nuisance article
HAS Harassment-general
HPO Harassment policy viol: sex/rel/race
INS Insubordination

LAN
NIS
NSD
PAS
PFI
PRK
PVI
PYR
RPH
RPO
TAR

Inappropriate language/gesture
No show in-school suspension
No show detention
Physical assault
Participant in fight
Parking violation
Physical violation
Pyrotechnics
Reported harassment
Report harassment pol. vio.
Tardy

TFT Theft
TOB Tobacco violation
TRE Trespassing
TRU Truancy
TVI Technology violation
UNX Unexcused absence
VAN Vandalism
VER Verbal/nonverbal assault
WEA Weapons violation

ACTION BY ADMINISTRATION Check Appropriate Action Code

AD
AD-IEP
ATS
BC
CR
CS
D
ISS
LP

Admin. Dismissal
Admin. dismissal Spec Ed
Alternative to suspension
Behavior contract
Counselor referral
Community service
Detention
In-school suspension
Learning plan/packet

LS
OSS
PC
PP
PR
PS
RS
SC
WA
OTHER

Locker search
Out-of-school suspension
Parent conference
Parent phoned
Police referral
Personal search
Restitution
Student conference
Warning

Comments:
Administrator:
Signature