Dear Student,

Your actions were disturbing the learning of other students. This is not okay. To
protect all students’ freedom to learn, I had to ask you to leave the classroom.

Everyone makes mistakes. I know you can do better. You can return to class when
you answer the following questions.

Thank you,
Mr. Grimes

1) What did you do that made me think you were disturbing the learning of others?

2) Why did you do that?

3) How does being asked to leave class affect your goals for the school year?
 It makes it harder to achieve my goals.
 It makes it easier to achieve my goals.
 It has no effect on my goals.
 Other:

4) Explain your answer to #2. (Fill in this sentence.)

Being asked to leave affects my goals for the school year because

5) How confident are you that you can return to class and help yourself and others
learn?
 Very confident--I have figured out what I need to do.
 Kinda confident--I may need some help staying on track. I may not do all
of the work but at least I won’t bring other students’ down with me.
 Not so confident --I am not sure how to control my behavior and need
help with this.

6) What else do you need to tell Mr. Grimes?