St. Lucie West K- 8 School
THE SCHOOL BOARD OF ST. LUCIE COUNTY
STUDENT INCIDENT FORM
Student Name
Student ID #
Grade
Date
Time
Referring Teacher
Homeroom Teacher
Location
Extended Day
y
Classroom
Bus Zone
Hallwayy
Special Event
Assembly
Bus #______
Restroom
Assembly
Other ________________
Media Center
Cafeteria
Expectation Violation
Check one violation
Possible Motivation
Check one motivation
Lying
Intervention
Check ALL that apply
Obtain peer attention
Date
Reteach Expectations
Tardy
Obtain adult attention
Student Conference
Misuse of property
Obtain items/activity
Seat Change
Disruption
Avoid peers
Note in planner
Not following directions
Avoid adults
Note/e-mail home
Teasing
Avoid task/activity
Peer mediation
Inappropriate Language
Parent Conference
Inappropriate Physical Contact
Time-out (in class)
_______________________
Time-out (out of class)
Loss of privilege
3rd Incident
Curricular accommodations
Refer to guidance
Date of 1st Incident
Refer to New Horizons
____________________
Student Contract
Weekly progress report
Date of 2nd Incident
Team Conference
____________________
Other _________________
Incident Description: ____________________________________________________________________________________
*** We are asking for your help since this is the 3rd occurrence of the same specific behavior within a semester.
Please discuss an appropriate alternative behavior with your child. A 4th occurrence will result in your child
receiving a referral to the Dean's office.
PARENT SIGNATURE REQUIRED
Teacher Signature:
Parent Signature: ____________________________________
Student Signature: ________________________
Parent Comments: _____________________________________________________________________________________
______________________________________________________________________________________________________
Signed form needs to be returned the next school day to referring teacher.
White Copy - Parent
Yellow Copy - Referring Teacher
Pink Copy - Team Leader
Gold Copy - Dean's Office
SLM0002
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