Simons PBIS Reflection Form
Name_____________________________________ Teacher_________________ Period ____ Date_________
I was not following Simons’ behavioral expectation of being:  Safe  Responsible  Respectful
1. What was I doing?
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_______________________________________________________________________________________
_______________________________________________________________________________________
2. What was I supposed to be doing?
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_______________________________________________________________________________________
_______________________________________________________________________________________
Am I doing it?
YES
NO (Circle one)
3. What actions must I take to be  safe,  responsible, and  respectful?
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
4. What should happen if I choose to not be safe, responsible, and respectful?
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_______________________________________________________________________________________
_______________________________________________________________________________________
5. Student/Teacher Conference (Tier I intervention)
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Teacher Signature _____________________________ Student Signature_____________________________