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Imagine Academy of Careers M.S.

Office Discipline Referral

Student Grade Date Time


Staff Member Parent #
Issue of Concern
Level I Offense Level II Offense
Alcohol/Drugs Attendance
Assault/Battery Destruction of Property
Cheating Disrespect/Defiance/Insubordination
Electronic Devices Disorderly Conduct
Extortion Dress Code
Fighting Failure to serve Detention
Fire/Emergency Equipment Food/Drinks in the Hall
Group/Gang Fighting Gambling
Repeated School Violations Inappropriate Language
Sexual Misconduct Destruction of School Property
Weapon Tardiness/Hall Sweep/Unsupervised
Smoking
Theft
Threats
Verbal Abuse
Description of Behavior

Location: Possible Motivation: Previous Actions Taken


Bus Attention of Peers Time-out
Cafeteria Attention of Staff Call Home
Hall Avoid Peers Teacher/Student Conference
Gym Avoid Work Parent Conference
Bathroom Obtain Items Resiliency
Classroom Other Office Referrals
Other
Administrative Consequences:

Parent Signature: Student Signature:


Administrative Signature:

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