STUDENT’S NAME DISCIPLINARY GRADE 03 04 05 06

ID# REFERRAL DATE OF INCIDENT

LOCATION OF INCIDENT COPIES TO: PARENT(S) TIME OF DAY/CLASS PERIOD OFFICE

TEACHER/STAFF MEMBER TEACHER(S)

DEPARTMENT HEAD

NOTICE TO PARENTS

1. The purpose of this notice is to inform you of a disciplinary incident involving your child.
2. Please note the action taken by the teacher/staff member and the corrective action initiated today.

REASON(S) FOR THIS NOTICE:

Major Behavioral Violations/Fast Track ____________________________________________________

__Weapons possession, threat to use or actual use ____________________________________________________

__Drugs & Alcohol sale, possession or use ____________________________________________________

__Serious verbal aggression, harassment or threat ____________________________________________________

__Serious damage to property ____________________________________________________

__Serious physical acts of violence ____________________________________________________

__Chronic violation of school/class rules ____________________________________________________

Other violations

__Disrespect of the physical & emotional rights of others ____________________________________________________

__Disrespect of property of self or others ____________________________________________________

__Lack of responsibility in following assigned daily schedule ____________________________________________________

__Disrespect for rules of classroom, library, cafeteria, campus, ____________________________________________________

hallway, bus & Co-Curricular activities ____________________________________________________

ACTION TAKEN BY TEACHER/STAFF MEMBER PRIOR TO THE NOTICE:

__Had conference with student/Script ____________________________________________________

__Time out and student/teacher plan ____________________________________________________

__Telephoned parent ____________________________________________________

__Changed student’s seat ____________________________________________________

__Detained after class/school ____________________________________________________

__Review of student’s file by teacher/staff member ____________________________________________________

__Consulted counselor ____________________________________________________

__Had conference with student, AEC and/or department head ___________________________________________________

__Had conference with parent ____________________________________________________

__Assigned to a new class ____________________________________________________

__Sent previous notice(s) Dates:_________________ ____________________________________________________

__Functional Academic/Behavioral Assessment/EST referral ____________________________________________________

PRESENT ACTION/RECOMMENDATION

__Student Behavior Plan ____________________________________________________

__Mediation ____________________________________________________

__Parent conference requested ____________________________________________________

__Detention as follows: ____________________________________________________

Dates:___________________ Length:____________ ____________________________________________________

__Placement in Alternative Education Center/ ____________________________________________________

In School Suspension ____________________________________________________

Dates of ISS:_________________________________ ____________________________________________________

__Out-of-School School Suspension ____________________________________________________

__Matter referred to:

________________________________ ______________________________________________________

ACTION TAKEN BY DATE