Massachusetts Department of Elementary and Secondary Education
Student Discipline Record 2014-2015
Below is a worksheet that corresponds to a single discipline record. If you have any questions about this worksheet, please contact your Data Collection
support specialist.
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Offense Date _______ / _______ / _______ (mm/dd/yyyy)
Please enter the date the offense occurred. Date must be during 2014-15 school year.
Offense ID _________________________
SASID _________________________
Please enter the State Assigned Student Identification number for the student.
First Name _________________________
Last Name _________________________
Date of Birth _______ / _______ / _______
Program Status (This information will automatically be displayed by the Department)
_____ 1. General Education
_____ 2. Student with Disabilities – student has an Individualized Education Plan
Disciplinary action taken (check only one)
_____ 1. In-school suspension (1 day – more than half the day or full day- or more)
_____ 2. Out-of-school suspension (1 day – either partial or full day - or more)
_____ 3. Expulsion
_____ 4. Removed by an impartial hearing officer to an alternative setting (only valid if program status = 2)
_____5. Removed by school personnel to an alternative setting (only valid if program status = 2)
_____6. Emergency Removal (not more than 3 days, inclusive of the day of removal)
Is this student being disciplined as the result of an offense that caused serious bodily injury?
_____ 1. Yes
_____ 2. No (Item 7b should only display if Program Status = 2. SWD)
Start Date ______ / ______ / ______ (mm/dd/yyyy)
Indicate date student was initially removed from school in this instance. Date must be during 2014-15 school year.
Complete only ONE of the following two items. (If student moved or transferred, complete 11-12 as if student remained enrolled there.)
Date Returned to School ______ / ______ / ______ (mm/dd/yyyy)
Indicate date if the student returned to school. If student was subject to an emergency removal, skip to #10.
Date Eligible to Return ______ / ______ / ______ (mm/dd/yyyy)
If the student has not yet returned to school and is eligible to return, indicate date eligible to return. Enter 09/01/15 if student was removed for
remainder of the 2014-15 school year.
If applicable, student was suspended for ____ additional days beyond the emergency removal, which are reflected in eligible date.
Number of school days missed due to disciplinary action _____
Count number of school days from the start date of removal/suspension/expulsion, to the return date or eligible return date, as applicable. For
removal/suspension through the end of the 2014-15 school year, or expulsions, count the number of days through the last day of the 2014-15 school
year.
Education Services were offered at the time of the suspension/expulsion and the student accepted the services for the duration of the
suspension/expulsion
_____ 1. Yes
_____ 2. No
Type of Education Services (Answer only if Yes is checked in 14 above)
If the district provided the student with education services, what services were provided?
_____ 1. Home tutoring
_____ 2. In-district education services (specify) ______________________________
_____ 3. Out-of-district education services (specify) __________________________________
_____ 6. Distance Learning
_____ 7. Saturday School
_____ 8. Other (specify) ______________________________________
**values 4-5 are discontinued
Education Services Not Provided (Answer only if No checked in 14 above)
Indicate the reason why the student was not provided with education services.
_____ 1. Moved/transferred
_____ 5. Refused services
_____ 6. Did not respond to the offer of services
_____ 7. Other (explain) ______________________________
**values 2-4 are discontinued
Extra suspension days ____
If applicable, report the number of additional days beyond the emergency removal, which are reflected in eligible date. Report 0 if Disciplinary action
is other than 6.
If suspended or expelled by the principal for more than ten days, did the student appeal the decision to the superintendent?
_____ 1. Yes
_____ 2. No
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Type Of Offense ID 1 _____
See Offense Type Codes on the Offense worksheet.
Type Of Offense ID 2 _____
See Offense Type Codes on the Offense worksheet. If additional offenses do not apply to this offense report default value of 500.
Type Of Offense ID 3 _____
See Offense Type Codes on the Offense worksheet. If additional offenses do not apply to this offense report default value of 500.
Type Of Offense ID 4 _____
See Offense Type Codes on the Offense worksheet. If additional offenses do not apply to this offense report default value of 500.
Type Of Offense ID 5 _____
See Offense Type Codes on the Offense worksheet. If additional offenses do not apply to this offense report default value of 500.