CHS Office Incident Referral Form

Student Referring Staf

Lawrence Coleman

Room # Grade Date Time of incident am/pm

11 10/23/2014

_______________________________________________________________________________________________________________________________________
Location
Classroom Media Center/Library Bus Loading Zone
Computer Lab Parking Lot Locker Room

Hallway Bus Stadium

Cafeteria Special Event/Assembly/field trip Gym
Bathroom Of Campus Other
_______________________________________________________________________________________________________________________
Minor Problem Behavior: (Check Only ONE)
Inappropriate Language Dress Code Violation
Physical contact/aggression Technology Violation
Defiance/disrespect/non-compliance Tardy
Disruption Other
Property Misuse
Staff Response to Behavior/Intervention:

Phone call home on Date: Time:

-----------------------------------------------------------------------------------------------------------------------------------------------------
--------------------------- Major Problem Behavior: (Check Only ONE)
Abusive language/inappropriate language/profanity Arson
Defiance/disrespect/insubordination Bomb threat
Disruption Gang Affiliation/display
Inappropriate display of
Dress code violation
afection
Inappropriate location/Out of
Fighting
bounds
Forgery/Theft Technology Violation
Harassment/Bullying Use/Possession of alcohol
Lying/Cheating Use/Possession of combustibles
Physical Aggression Use/Possession of drugs
Property damage Use/possession of tobacco
Skipping Use/possession of weapons
*Tardy (3 or more: Admin. Use) Other Behavior
Truancy
Comments:
 Substantial Disruption, Involved in a incident in the bathroomthat erupted in the hallway

Others Involved None Peer Staf Teacher Substitute Unknown

Other
______________________________________________________________________________________________________________________
Possible Motivation: Avoid Peer(s) Avoid Adult(s) Obtain Items/Activities
Avoid Tasks/Activities
Obtain Peer Attention Obtain Adult Attention Other Undetermined
Comments:

______________________________________________________________________________________________________________________
Administrative Decision: Time in office Loss of privilege Conference with student Parent
contact
Time out/detention Restitution Community service Individualized instruction Bus
suspension OSS ISS
Saturday school Expulsion Other
Back on trach two days 10/28-29/2014

Unknown

Staff Signature: ______________________________________________________

Date:______________________________
Administrator Signature: _______________________________________________ Date:
_______________________________
Parent Signature: _____________________________________________________ Date:
______________________________
Student Signature: ____________________________________________________ Date:
______________________________