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: