St. Lucie County School District
LINCOLN PARK ACADEMY
Minor Infraction Report
Student Name (Last, First, Middle Initial)
Grade Level
Date
Time
Referring Teacher
HR Teacher
Incident Location: (Circle One)
1. Bathroom/Restroom
7. Library
2. Bus Ramp
8. Office
3. Cafeteria
9. Bus #_____
4. Classroom
10. Other
5. Commons/Common Area
11. Playground
6. Gymnasium
Possible Motivation: (Circle One)
1. Avoid Adult
5. Obtain Adult Attention
2. Avoid Peers
6. Obtain Items/Activities
3. Avoid Task/Activities
7. Obtain Peer Attention
4. Don’t Know
8. Other
Expectation Violated: (Circle One)
Respectful
Responsible
Ready to Learn
Incident Type: (Circle One)
1. Dress Code
2. Inappropriate Lang.
3. Disruption
4. Defiance/Disrespect
5. Lying
Intervention: (All that Apply)
1. Student Conference______
2. Re-teach Expectation
3. Seating Change
4. Letter to Parent
Incident Description:
6.
7.
8.
9.
Teasing
Property/Damage
Chewing Gum
Other_________________
5.
6.
7.
8.
Phone Parent______
9. Time Out
Peer Mediation______
10. Loss of Class Privilege
Parent Conference______
11. Refer to Guidance
Curricular Modification______
12. Sent to Rm. #
(Please sign and return to school)
13. Student Contract
14. Other_________
_____________
Parent Signature
Parent Comments
Rev.9/09
LPA0008
St. Lucie County School District
LINCOLN PARK ACADEMY
Minor Infraction Report
Student Name (Last, First, Middle Initial)
Grade Level
Date
Time
Referring Teacher
HR Teacher
Incident Location: (Circle One)
1. Bathroom/Restroom
7. Library
2. Bus Ramp
8. Office
3. Cafeteria
9. Bus #_____
4. Classroom
10. Other
5. Commons/Common Area
11. Playground
6. Gymnasium
Possible Motivation: (Circle One)
1. Avoid Adult
5. Obtain Adult Attention
2. Avoid Peers
6. Obtain Items/Activities
3. Avoid Task/Activities
7. Obtain Peer Attention
4. Don’t Know
8. Other
Expectation Violated: (Circle One)
Respectful
Responsible
Ready to Learn
Incident Type: (Circle One)
1. Dress Code
2. Inappropriate Lang.
3. Disruption
4. Defiance/Disrespect
5. Lying
Intervention: (All that Apply)
1. Student Conference______
2. Re-teach Expectation
3. Seating Change
4. Letter to Parent
Incident Description:
6.
7.
8.
9.
Teasing
Property/Damage
Chewing Gum
Other_________________
5.
6.
7.
8.
Phone Parent______
9. Time Out
Peer Mediation______
10. Loss of Class Privilege
Parent Conference______
11. Refer to Guidance
Curricular Modification______
12. Sent to Rm. #
(Please sign and return to school)
13. Student Contract
14. Other_________
_____________
Parent Signature
Parent Comments
Rev.9/09
LPA0008