Minor Infraction Form Student Name_______________________ Homeroom______________________ Be Safe Be Responsible Be Respectful 1st Minor Infraction Date/Time____________ Classroom______________ Behavior Intervention: Disruptive Dress Code Electronic Device Physical Contact Inappropriate Language Defiance Stealing Sleeping Minor dishonesty Throwing Disrespect Physical contact Property Misuse Other__________________ Planned ignoring Redirect Private Conversation Phone call home Relaxation exercises/sensory Removal student/Class Loss of privileges ABIL Walk Self- Contain Stu/teacher negotiated Reinforcement Natural Consequence Journaling Other__________________ Incident Description: ______________________ Comments: Restate Expectation & Re-teach _________________________________________ _________________________________________ _________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ Be Safe 2nd Minor Infraction Behavior Disruptive Dress Code Electronic Device Physical Contact Inappropriate Language Defiance Stealing Be Responsible Be Respectful Date/Time____________ Classroom______________ Intervention: Sleeping Minor dishonesty Throwing Disrespect Physical contact Property Misuse Other__________________ Planned ignoring Redirect Private Conversation Phone call home Relaxation exercises/sensory Removal student/Class Loss of privileges ABIL Walk Self- Contain Stu/teacher negotiated Reinforcement Natural Consequence Journaling Other__________________ Incident Description: ______________________ Comments: Restate Expectation & Re-teach _________________________________________ _________________________________________ _________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ Be Safe 3rd Minor Infraction Behavior Disruptive Dress Code Electronic Device Physical Contact Inappropriate Language Defiance Stealing Be Responsible Be Respectful Date/Time____________ Classroom______________ Intervention: Sleeping Minor dishonesty Throwing Disrespect Physical contact Property Misuse Other__________________ Planned ignoring Redirect Private Conversation Phone call home Relaxation exercises/sensory Removal student/Class Loss of privileges ABIL Walk Self- Contain Stu/teacher negotiated Reinforcement Natural Consequence Journaling Other__________________ Incident Description: ______________________ Comments: Restate Expectation & Re-teach _________________________________________ _________________________________________ _________________________________________ ___________________________________________________ ___________________________________________________ ___________________________________________________ 4th Minor Infraction Write an Office Discipline Referral. Attach and submit this Minor Infraction Form with Office Discipline Referral to office.