Be Respectful

Edison Elementary School

Be Responsible
Minor/Major Behavior Infraction
Be Safe

Be Motivated

Date: ______________ Time: ____________ Referring Staff: ______________________________

Student: _____________________________  IEP  504 Teacher: _____________ Grade: _____

Location:
 Classroom  Gym  Music Room  Special Event/ Assembly/ Field Trip
 Hallway/Breezeway  Office  21 Century
st
 Media Center
Playground  Bathroom  Art Room  Library
 Computer Lab  Cafeteria 
Other:______________
_
Problem Behaviors
Minors (Teacher
Managed): Major (Office Managed):
 Disrespect  Excessive/Repetitive Swearing, Leaving the building, Theft of major objects
 Disruption  Disruption (Yelling excessively, Throwing objects with intent to harm, Out of control behavior in
the extreme)
 Inappropriate  Inappropriate Language (Blatant or Excessive, Severe Bullying – Verbal, Harassment,
Language Intimidation)
 Property  Property Damage/Misuse (Excessive, Permanent, Vandalism)
Damage/Misuse
 Physical Contact  Physical Contact (Fighting/Repeated Physical Aggression, Loss of Control Out of Anger, Intent to
Harm)
 Technology Violation  Technology Violation (Accessing “off limit”, inappropriate websites, bullying/harassment on
school equipment)


Other:
Other:
s
What Happened (TEACHER): ____________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Possible Motivation: Others Directly Involved

 Avoid Adult(s)  None
 Avoid Peer(s)  Peers
 Avoid Task(s)/Activities/Sensory  Teacher
 Obtain Adult(s) Attention  Substitute
 Obtain Peer(s) Attention  Unknown

Teacher/ Administrative Decision:

 Time Out (Time out or Time in Office)  Loss of Privilege(s)
 Alternative Placement  Restorative Practices
 Conference with Student (Problem-Solving, Mediation)  In-School Suspension:
 Restitution (Apology, Community Service)  Out of School Suspension:
 Parent (Contact, Conference)  Seclusion
 Instruction (Teach Correct Behavior or Reteach)  Restraint
 Other: _________________________________

WHITE: Parent Copy YELLOW: Teacher Copy PINK: Office Copy

Be Respectful
Edison Elementary School
Be Responsible
Referral Form Descriptions
Be Safe
Minor vs. Major Behavior Guidelines
Be Motivated

Behavior Minor (Teacher Managed) Major (Office Managed)

Disrespect  Making faces/ Rolling eyes  “F-you”, flipping off, etc.
 Arguing/defiance  Repetitive minor incidences that normal
 Inappropriate classroom consequences are not addressing
Response to Teacher Request  Leaving the building/Hiding from staff
 Talking back  Theft of major objects or pattern of minor
 Cheating/Lying stealing that is ongoing
 Leaving assigned area without permission
 Minor object stealing
 Forgery (Signing a parent name)
Defiance  Intentional refusal to follow adult requests  Excessive and repetitive refusal to follow
 Talking back adult requests
 Projecting blame on others  Challenging/Threatening Authority
 Intentionally doing the opposite of what is
asked
Disruption  Repetitive yelling out or blurting  Screaming/Yelling excessively
 Excessive disruption during instruction  Out of control behavior in the extreme
 Throwing objects  Throwing objects with the intent to cause
harm

Inappropriate  Name calling  Blatant or excessive swearing

Language  Swearing (Not Directed at anyone)
 Verbal argument/disagreement
 Talking back
 Dishonesty/ Lying
 Peer conflict (Balance of power)
 Mean comments that hurt feelings
 Excessively vulgar language
 Severe verbal threats against anyone
 Harassment (Racial, sexual, religious, gender,
ability)
 Intimidation
 Bullying (Imbalance of power)

2
Property  Defacing books, pencils, pens, crayons,  Excessive defacing of peer/teacher/school
Damage/Misuse classroom supplies, etc. property
 Minor vandalism (such as writing on desk or  Vandalism (Permanent Damage)
other’s property)  Throwing furniture or school supplies with
 Pushing over or tipping school property the intent to harm

Physical Contact  Bumping into another person  Fighting

 Pushing/ Shoving  Physical aggression with intent to harm
 Poking  Physical intimidation
 Tripping  Spitting/Scratching/Biting with intent to
 Reckless physical behavior such as: play harm- anger related
hitting/ horseplay/ flicking/ pinching/ teasing-  Sexual misconduct
messing around intent
Technology  On a website or app without permission  Accessing “off limit” and inappropriate
Violation  Using technology to communicate with peers websites on school computer
at instructional times  Bullying/ Harassment type messages on
school tech equipment