Fillable JPSD - Office Discipline Behaviour Referral

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JPSD - Office Discipline Behaviour Referral

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Country of origin: US
File type: PDF

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JPSD Office Discipline-Behavior Referral
Student Information:
Last Name:
First Name:
MSIS ID #
Gender:
M F
Birthdate:
Grade:
Parent / Guardian Name(s):
Phone Numbers:
Incident Information:
-----------------------------------School Administrator Use Only-----------------------------------
Revised 9/2017
Signatures: Student __ Parent ___ Administrator _____________________ Data Entry (Initial)
School Name
Referral #
Location:
Problem Behavior: (Check one)
Classroom Hallway
Cafeteria Restroom
Gym
Library
Bus Loading Zone
Bus (# )
Special Event Office
Common Area Other
Location
(List):
Others Involved: Attach
reports with names):
None
Peers
Staff
Teacher Substitute
Unknown
Other
Reason for Behavior:
Obtain Peer Attention
Obtain Adult Attention
Obtain Items/Activity
Avoid Task/Activity
Avoid Work
Avoid Peers Avoid
Adults
Unknown Motivation
Other
Provide
documentation of
interventions
Abusive Language to Staff
Abusive Language to Student
Academic Cheating
Alcohol Possession*
Arson (1
st
& 2
nd
)*
Assault on Student
Assault on Staff***
Behavior that Threatens the Health, Safety, or
Welfare of Students or Staff
Bomb Threat*
Bullying/Cyber-Bullying***
Coercion (Secondary Level)
Cutting Class
Dangerous Instruments Possession/Concealment/Sale***
Defiance of School Authority
Dress Code Violation
Drugs/Controlled Substances (Possession, Use,
Purchase, and/or Distribute)*
Electronic Device Violation
Excessive Tardiness
Extortion***
Falsification - Verbal
Fighting/Inflicting Serious Bodily Injury***
Forgery
Gambling
Group Fight
Harassment - Sexual
Harassment / Intimidation (Students)
Harassment / Intimidation (Staff)
Homicide***
Inappropriate Behavior
Indecent Liberties with a Minor*
Initiating or Instigating a Disturbance/Fight
Kidnapping***
Late to Class/Tardy
Leaving School Without Authorization
Leaving the Classroom Without Permission
Loitering/Student Presence in any Prohibited School
Area
Misuse of Technology - Including Severe Clause
Nonprescription or Non-Controlled Substance
(Possession, Use, Purchase, and/or Distribute
Offensive/Unwanted Touching (Staff)
Offensive/Unwanted Touching (Student)
Participation in Gang-Related Activity***
Poisoning***
Possession of Explosives/Incendiary Device
Possession of Passed Along Stolen Property
Public Indecency, Lewdness, or Exposure
Rape/Attempted Rape***
Reckless Burning /Arson 3
rd
*
Robbery***
Sexual Assault***
Smoking/Possession of Tobacco/Tobacco Products
Stealing
Tampering with any Fire Safety Device
Theft Using Extortion*
Threatening Behavior - Staff
Threatening Behavior - Student
Trespassing*
Unlawful Sexual Contact/Battery***
Use of Explosives/Incendiary Device
Vandalism*
Weapon(s)Possession/Concealment/Sell/Purchase***
Note:*State Law
***Persistently Dangerous/State Law/Code
Date:
Time:
AM PM
Referring Staff:
Briefly Describe Problem (Attach additional page if necessary):
Administrative//Strategy/Intervention/Decision
Student Conference
Administrative Inquiry
Review of Behavioral Supports
Restorative Discipline/Practice
Parent Contact
Referral to School-Based Counselor
IEP Committee Mtg.
Referral to MTSS/PBIS
Student/Administrator/Parent Conference
Behavior Contract
Loss of privileges/restricted from activities
Detention - Before/After School
In-School Detention
In-School Suspension
Out-of School Suspension
Expulsion
Refer to Support Agency
Bus Suspension
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JPSD - Office Discipline Behaviour Referral

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Completed 26 May 2020

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