St. Lucie Public Schools
Bus Safety Referral
Student Name: _________________________________________________ Student ID #: __________________________________
School: ______________ Grade: _______ Gender: ____________ Incident Date: ______________ Time: _________ Bus # _________
Check if applicable:
Student has an IEP
Student has a 504 Plan
Student has a Behavior Plan
DETAILED description of incident (Include WHO, WHAT, WHEN, WHERE, WHY): _________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Context of incident (check one):
1 During school hours
2 Outside school hours-school sponsored activity
3 Outside school hours-non-school sponsored activity
Where incident occurred (check one):
1 School grounds/on campus
2 School-sponsored activity/off campus
3 School-sponsored transportation (including bus stops)
School where incident occurred if other than home school: ______________________________________________
9001 Non-school location
Incident Location (check one):
AT Activity Trip
AU Auditorium
BR Bus Ramp
BS Bus Stop
BU School Bus
CA Cafeteria
CL Classroom
FT Field Trip
GY Gym
HL Hallway
LR Locker Room
MC Media Center
OF Office
PE Playground/PE
PK Parking Lot
RR Restroom
99 Unknown
SG School Grounds/Commons Area
ST Stadium
Participants involved in incident (check one):
S- Student
N- Non-student
*input in ITYPE field on A24
B- Both student and non-student
U- Unknown
Prior action taken before referral (check one):
1- Conference with pupil
5- Re-teach expectations
2- Referred to Counselor
3- Placed pupil in detention
4- Other action _________________________________
6- Parental contact ____________________________________________ (date)
Phone
Letter
Conference
Possible motivation (check one):
1- Avoid Adult
5- Avoid Peers
2- Avoid Task/Activities
6- Obtain Items/Activities
3- Obtain Adult Attention
7- Don’t Know
4- Obtain Peer Attention
8- Other: ______________________________
Reported by (check one): Staff ID #s should be used. Persons without staff ID #s should use the following codes:
980 Area Manager (Trans)
975 Asst. Principal
978 Bus Attendant
963 Bus Driver
977 Campus Aide
962 Classroom Aide
964 Clerical
965 Crossing Guard
966 Custodian
976 Dean
967 Food Service Staff
968 Law Enforcement Officer
973 Other
969 Parent/Guardian
974 Principal
972 School Volunteer
979 Security
970 Student
971 Sub Teacher
Security Initials________________
Reported by (signature): __________________ Print Name: ___________________ Date: _______ Area Manager Initials: _____
Administrative Use Only
(Required)
Date received or date stamped by clerk:__________________________ Date Action Taken:________________________________
Action by Administration
Incident Description Code: ____________________________
Discipline Response/Action Code(s): __________________________
(see back of form for codes)
If suspended: (check one)
CONTACT WITH:
out of school
(see back of form for codes)
in- school
bus, for ________ days beginning ____________through _____________
(beginning date)
(Last day of suspension)
__________________________________________phone #_______________time _______ email ___________________________________
If parent conference was requested, give date and time of conference: ________________________________________________________________
COMMENTS:______________________________________________________________________________________________________
Other data (check if appropriate):
Gang related
Injury Related:
Alcohol Related
Marijuana/hashish/other cannabinoids
Other Illicit Drugs
Hate Related
 Harassment /Bullying related: reason suspected__________________________________________________________
A - More Serious
Weapons description:
 More than 1 weapon used
B – Less Serious
F-Firearm, Other
R- Rifle or Shotgun
Z – No serious bodily injury involved
H-Handgun
U- Unknown Weapon
K- Knife
O- Other Weapon
Reported to Police: ____________ Date, time and to whom reported: _______________________ Case # ___________________
(Required for level IV)
(initial)
Administrator Signature: ___________________________________Parent/Student signature:________________________________
Incident # _________________
White: School Administrator
MI # _________________
Canary: Administrator Returns to Bus Driver with Disposition Pink: Transportation Manager Gold: Bus Driver TRA0040 Rev.11/11