Steuart Hill Academic Academy #004

Classroom Intervention
Student: ______________________________________________________ Grade: ______________ Team: _____________
Referring Staff: _______________________________________________Date: ________________ Time: _______________

Location:

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Bathroom
Gymnasium
Cafeteria

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Classroom
School Grounds
Hallway

Library/Computer Lab
Auditorium

Recess

Other:__________________

Staff Managed Behavior (SMB) (chronic infractions: refer to Response System chart): Submit SMB form with Referral

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Absences (103) Fighting (may include incidents resulting in minor injuries) **

Academic Dishonesty (801)

Attack on Student (402) **

Bullying, Including Cyberbullying and

Gang Related Incidents (407) **

Class Cutting (101) **

Classroom Disruption (704)

Defiance of Authority and/or Insubordination

Failure to follow directions (807) Failure to respond to school staff questions or requests (702)
Disrespectful Behavior (701)
offensive language

Making inappropriate gestures, symbols, or comments, or using profane or

Using verbal insults or put downs or lying to,

misleading, or giving false information to school staff Dress Code Violation (807)
Fighting (405) ** Physical aggression with another student (e.g., shoving or pushing)
Hallway Misbehavior (705)
Harassment Based on Race, Ethnicity, Gender,
Sexual Orientation, Disability, or Religion (703) **

Portable Electronic Device Use at Unauthorized Times (802)

Property Damage, Including Graffiti (806) **

Refusal to Obey School Policies (807)

Tardiness (102)

Theft (803) **

Verbal or Physical Threat to Student (404) **

Other_________________________________

Possible Motivation: Check the violations that apply.

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Obtain Peer Attention

Obtain Adult Attention
Obtain Items/Activities

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Avoid Task/Activities
Avoid Peers
Avoid Adults

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Unclear/Dont Know
Other________________________

Detailed Description: (quote when possible) ______________________________________________________

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Others Involved: _________________________________________________________________________________

Teacher Intervention: (If other, describe in comments below)

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Conference with Student/warning

Parent contact: call
(mother/father/guardian), letter
Conference with teacher/parent
Team Intervention

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Lunch Detention

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Written Contract

After School Detention

Out-of-Class Time-Out

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Privilege Loss

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Home/School Plan

Apology Restitution

Buddy System

Other________________________________________________________________________________________________________

Comments:
Teacher Signature:

Date:

Inap