DISCIPLINARY REFERRAL FORM
Student Information:
Name:
Grade:
Incident Details:
Date of Incident:
Time of Incident:
Location of Incident:
Type of Violation: ______________________________ (e.g., Disrespect, Disruption, Fighting,
Cheating, Vandalism, etc.)
Description of Incident: (Provide a detailed description of the incident, including the events
leading up to it and any witnesses.)
Teacher/Staff Member Reporting:
Name:
Position:
Contact Information:
Actions Taken: (Describe the immediate actions taken in response to the incident.)
Consequences Recommended: (Check all that apply)
•
•
•
•
•
•
☐ Warning
☐ Detention
☐ Suspension
☐ Parent/Guardian Conference
☐ Counseling
☐ Other: ______________________________
Additional Comments: (Include any additional information or observations.)
Parent/Guardian Notification:
Date of Notification:
Method of Notification: (e.g., Phone Call, Email, Letter, In-Person Meeting)
Parent/Guardian Response:
Follow-Up Actions: (Describe any follow-up actions or support provided to the student.)
Signature of Teacher/Staff Member Reporting:
Date:
Signature of Student:
Date:
Signature of Parent/Guardian
Date: