PBSD 0279 (Rev. 5/19/2016) RECORD COPY - Administration COPY - Parent COPY - Originator COPY - Guidance Counselor / ESE Contact
Description of Event (be specific)
Student Name (First, Middle Initial, Last)
Student Number Grade
Yes No
ESE/504
Date Military Time
- Bookstore
- Bus Stop
- School Bus/Transportation
- Cafeteria
- Clinic
- Regular Classroom
- School Grounds
- Gymnasium
- Hallway
- Alternative to Suspension
Room
- Laboratory
- Library/Media Center
- Office
- Off School Grounds
- Other
- Playground/Track
- Parking Lot
- Rest room
- Returning Home
- Field Trip/Activity
Off Campus
- To School
BK
BS
BU
CA
CL
CS
GR
GY
HA
IS
LA
LI
OF
OG
OT
PG
PK
RE
RT
TO
TR
Location
Report By School Bus Code
3-Digit Staff I.D.
- Paraprofessional
- Bus Driver
- Clerical
- Crossing Guard
- Custodian
- Food Service Staff
- Law Enforcement Officer
- Parent/Guardian
- Student
- Substitute Teacher
- School Volunteer
- Other
975
976
977
978
979
980
981
982
983
984
985
999
Reported By (Code) (Use
number below for those
persons w/o
a staff ID.)
Corrective Strategies/Interventions Prior to Referral (include date)
Student
Parent/Guardian
Counselor
Other
Detention
Assigned Mentor
Reflective Assignment
Loss of Incentives
Reteach/Model Expectations
SBT Referral
Mediation
Student Contract
BIP
Severe Offense
District Number
If not 50, provide District No.
School No.
If not home school provide School No.
HOME SCH.
DISTRICT 50
2 - Sponsored activity/off campus
Bullying
Based On:
R S D
SO
Related Issues (check all that apply)
If Weapon Used What Kind?
Incident Codes
(see code sheets)
ALL
Action Codes
(see code sheets)
ALL
Administrator's Name
Comments
Law Enforcement Notified
Duration
How many days?
Begin Date
Return Date
Case Number/Agency
Administrator's I.D. Event Number Date
Signature of Parent Date
DateSignature of Student
TRESPASSING NOTICE: I, the student, am aware that I may not be
on school grounds and may not attend any school functions or
school activities on or off school grounds of any Palm Beach County
School District facility during the dates of my suspension.
CRT/PCM Team Intervention
Yes No
4 - Unrelated event or unknown
3 - Outside school hours, non-school sponsored activity
2 - Outside school hours, school sponsored activity
1 • DURING SCHOOL HOURS
When Event Occurred (check one)
THE SCHOOL DISTRICT OF PALM BEACH COUNTY
A- Alcohol related
G - Gang
related
W - Weapon
related
H - Hate
related
0 · Drug
related
ADMINISTRATIVE USE ONLY BELOW THIS LINE
1 • SCHOOL GROUNDS/ ON CAMPUS
Where Event Occurred (check one)
3 - School sponsored transportation
(includes bus stops)
Harassment
K -Knife
H - Handgun
F -Firearm/Explosive
Device
R - Rifle/Shotgun
O - Other
Weapon
U - Unknown
Student Discipline Referral
Conference With:
DIRECTIONS: Write in the appropriate code number or letter in the corresponding boxes.
RE
