Floresta Elementary School
St. Lucie County Schools
Classroom Intervention Record
Student Name (Last, First)
Grade Level
Date
Time
Referring Staff Member
Classroom Teacher
Incident Location: (Circle One)
Possible Motivation: (Circle One)
1. Bathroom/Restroom 7. Media
1. Avoid Adult
5. Obtain Adult Attention
2. Bus Ramp
8. Office
2. Avoid Peers
6. Obtain Items/Activities
3. Cafeteria
9. Bus #_________
3. Avoid Task/Activities
7. Obtain Peer Attention
4. Classroom
10. Playground
4. Don’t Know
8. Other
5. PE Area
11. Hallway
Expectation Violate: (Circle One)
6. Field Trip
12. Resource
Respect
Responsibility
Safety
Positive Attitude
Incident Type: (Circle One)
Incident Description: (Observable &
Measurable):__________
1. Dress Code
7. Harassment/Tease/Bully
___________________________________________________
2. Inappropriate Lang.
8. Property Damage (<$5)
3. Disruption
9. Theft (<$5)
___________________________________________________
4. Defiance/Disrespect
10. Chewing Gum
5. Lying
11. Other_______________
___________________________________________________
6. Cheating
Intervention: (All that Apply)
1.
2.
3.
4.
5.
Re-teach Expectation (Mandatory)
Student Conference____________
Seating Change
Letter to Parent
Phone Parent_____________
Teacher
Student
6.
7.
8.
9.
10.
Peer Mediation____________
Parent Conference__________
Curricular Modification
Time Out in class
Loss of class privilege
11. Refer to Guidance
12. Sent to_____________’s Room
Length of time___________
13. Apology
14. Student Contract
Other________________
(Please sign and return to school)
Parent Signature_________________________________________________________ Date_________________________
Parent Comments_____________________________________________________________________________________________
_____________________________________________________________________________________________________________
White:
Canary:
Pink:
FLE0002 Rev. 6/06
Floresta Elementary School
St. Lucie County Schools
Classroom Intervention Record
Student Name (Last, First)
Grade Level
Date
Time
Referring Staff Member
Classroom Teacher
Incident Location: (Circle One)
Possible Motivation: (Circle One)
1. Bathroom/Restroom 7. Media
1. Avoid Adult
5. Obtain Adult Attention
2. Bus Ramp
8. Office
2. Avoid Peers
6. Obtain Items/Activities
3. Cafeteria
9. Bus #_________
3. Avoid Task/Activities
7. Obtain Peer Attention
4. Classroom
10. Playground
4. Don’t Know
8. Other
5. PE Area
11. Hallway
Expectation Violate: (Circle One)
6. Field Trip
12. Resource
Respect
Responsibility
Safety
Positive Attitude
Incident Type: (Circle One)
Incident Description: (Observable &
Measurable):__________
1. Dress Code
7. Harassment/Tease/Bully
___________________________________________________
2. Inappropriate Lang.
8. Property Damage (<$5)
3. Disruption
9. Theft (<$5)
___________________________________________________
4. Defiance/Disrespect
10. Chewing Gum
5. Lying
11. Other_______________
___________________________________________________
6. Cheating
Intervention: (All that Apply)
1.
2.
3.
4.
5.
Re-teach Expectation (Mandatory)
Student Conference____________
Seating Change
Letter to Parent
Phone Parent_____________
Teacher
Student
6.
7.
8.
9.
10.
Peer Mediation____________
Parent Conference__________
Curricular Modification
Time Out in class
Loss of class privilege
11. Refer to Guidance
12. Sent to_____________’s Room
Length of time___________
13. Apology
14. Student Contract
15. Other________________
(Please sign and return to school)
Parent Signature_________________________________________________________ Date_________________________
Parent Comments_____________________________________________________________________________________________
_____________________________________________________________________________________________________________
White:
Canary:
Pink:
FLE0002 Rev. 6/06