St. Lucie Public Schools
Dan McCarty School
EAGLES POSITIVE BEHAVIOR SUPPORT (PBS)
INTERVENTION REPORT
GOAL: To increase time on task and improve academic achievement by reducing/eliminating problematic behavior.
Student: _____________________________________ Teacher: ___________________________
Grade: ______ Team: _________________________ Subject: _____________________________
Parent/Guardian: _________________________________________________________________
Phone/Home: ______________________________ Work: ________________________________
Beeper/Cell: ______________________________ Other: _________________________________
DATE
No. 1 INFRACTION
INTERVENTIONS
EXPECTATIONS
VIOLATED
No. 2 INFRACTION
INCIDENT
LOCATION
INTERVENTIONS
EXPECTATIONS
VIOLATED
No. 3 INFRACTION
INCIDENT
LOCATION
INTERVENTIONS
TIME
POSSIBLE
MOTIVATION
DATE
TIME
POSSIBLE
MOTIVATION
DATE
06
TIME
POSSIBLE
MOTIVATION
DATE
EXPECTATIONS
VIOLATED
No. 4 INFRACTION
POSSIBLE
MOTIVATION
DATE
INCIDENT
LOCATION
INTERVENTIONS
08
TIME
PARENT CONTACT
PHONE CALL
STUDENT DISCIPLINE
REFERRAL
EXPECTATIONS
INCIDENT
VIOLATED
LOCATION
PARENT CONTACT METHOD
TIME
NOTES
All referrals that are sent to the office will be addressed by an administrative staff member in a timely manner.
White:
DISRUPTIVE INCIDENTS
INTERVENTIONS
POSSIBLE MOTIVATION
A=DISRESPECTFUL TO STAFF/DEFIANT/RUDE &
DISCOURTEOUS BEHAVIOR
B=DISRUPTING CLASSMATES
C=INAPPROPRIATE LANGUAGE
D=REFUSAL TO FOLLOW DIRECTIONS
E=AGGRESSIVE BEHAVIOR
F=CHEWING GUM/CANDY
G=TARDY
H=DRESS CODE VIOLATION
I=LEAVING SEAT WITHOUT PERMISSION
J=EXCESSIVE TALKING OR NOISEMAKING
K=REPEATED MISCONDUCT
L=PROPERTY MISUSE/TECHNOLOGY
VIOLATION
M=OTHER DISRUPTION
01=REPRIMAND/WARNING
02=SEAT CHANGE
03=OPPORUNITY TO IMPROVE “OTI” AREA
04=STUDENT/TEACHER CONFERENCE
05=ALTERNATIVE STRUCTURE (Removal to another
classroom)
06=PHONE CALL
07=WRITTEN COMMUNICATION HOME
(planner, letter, etc)
08=REFERRAL
09=OTHER
OPA=OBTAIN PEER ATTENTION
OAA=OBTAIN ADULT ATTENTION
ATA=AVOID TASKS/ACTIVITIES
AP=AVOID PEER(S)
OIA= OBTAIN ITEMS/ACTIVITIES
AA=AVOID ADULT(S)
Canary:
Pink:
EXPECTATION VIOLATED
GR=GIVE RESPECT
AR=ACT RESPONSIBLE
RTL=READY TO LEARN
EIS=EVERYONE IS SAFE
INCIDENT LOCATION
RR=RESTROOM
CAF=CAFETERIA
HW=HALLWAY
GYM=GYMNASIUM
MC=MEDIA CENTER
CR=CLASSROOM
DMS0001 Rev. 12/07
St. Lucie Public Schools
Dan McCarty School
EAGLES POSITIVE BEHAVIOR SUPPORT (PBS)
PARENT NOTIFICATION FORM
DATE: _________________________
_______________________________
Dan McCarty Middle School
1201 Mississippi Avenue
Fort Pierce, Florida 34950
TO THE PARENTS OF _____________________________________:
From time to time students begin to develop school habits that can lead to more serious
problems. I like to notify parents of this change as early as possible in order to remedy the situation
before it progresses.
The incidents of which I am speaking of are listed on the back of this letter and are becoming
more serious. I have made the appropriate interventions and would appreciate you discussing the
matter at home with your child to see if we can improve the situation before further consequences are
needed.
Please use the box below to provide current contact number(s). If, for any reason, a fourth
intervention occurs, a student discipline referral will be generated.
Thank you for your cooperation.
Please return this form to me with your signature so that I may be certain you have seen it.
Include any comments you wish and if you would like to discuss this with me please contact the
school at (772) 468-5700 Ext.________. The best time to call is _____________.
Parent Comments: ______________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Please Provide A Phone Contact:
Parent/Guardian: ________________________________________________________________
Phone/Home: _____________________________ Work: ________________________________
Beeper/Cell: _______________________________ Other: _______________________________
Parent Signature: _____________________________________________ Date: ____________________
Student Signature: ____________________________________________ Date: ____________________
Teacher Signature: ___________________________________________ Date: ____________________