TEMPE UNION HIGH SCHOOL DISTRICT
REFERRAL FORM
STUDENT:
STUDENT ID:
REFERRING STAFF MEMBER:________________________________________ DATE: ________TIME OF INCIDENT: ________
REASON FOR REFERRAL:
Location of Incident: _______________________________________ PARENT/GUARDIAN:____________________________________
TEACHER/STAFF ACTION BEFORE REFERRAL (Check Appropriate Boxes)
Student Conference
Detention
Phone Parent
Parent Letter
Parent Conference
COMMENTS:
White copy – Teacher
Yellow Copy - Administration
Other ____________
TEMPE UNION HIGH SCHOOL DISTRICT
NOTICE OF DISCIPLINARY ACTION
STUDENT:
STUDENT ID:
PARENT/GUARDIAN:________________________________________ DATE: ________TIME OF INCIDENT:
________
INCIDENT CODES (Check all boxes that apply/circle the main infraction)
Academic Misconduct/Dishonesty
001. Cheating
002. Forgery
003. Lying
004. Plagiarism
Aggression
005. Verbal Provocation
006. Minor Aggressive Act
007. Disorderly Conduct
008. Recklessness
009. Endangerment*
010. Fighting*
011. Assault*
012. Aggravated Assault**
013. Kidnapping**
014. Homicide**
015. Other Aggression: _____
Alcohol Violation
016. Distribution or Share**
017. Use or Possession**
018. Sale**
Arson
019. Of a Structure or Property*
020. Of an Occupied Structure**
Attendance Policy Violation
021. Leaving School Grounds w/out
022. Tardy
023. Truancy
024. Unexcused Absence
025. Other Attendance Violation
Drug Violation
026. Drug – Distribute or Share**
027. Drug –Use or Possession**
028. Drug – Sale**
Sexual Offenses
048. Harassment, Sexual*
Harassment, Threatening, & Intimidating
049. Harassment, Sexual w/Contact*
029. Bullying
030. Harassment, Nonsexual
031. Hazing
032. Threatening or Intimidating
050. Indecent Exposure
051. Pornography
052. Sexual Abuse**
053. Sexual Assault**
Technology, Improper Use
054. Computer
055. Network Infraction
056. Telecommunication Device
057. Other Technology
Theft
058. Petty Theft
059. Theft
060. Burglary (10 Degree)**
061. Burglary (20/30 Degree)*
062. Extortion
063. Robbery
064. Armed Robbery**
Other Violations of School Policies
033. Combustible
034. Contraband
035. Defiance or Disrespect
036. Disruption
037. Dress Code Violation
038. Gambling
039. Language, Inappropriate
040. Negative Group Affiliation
041. Parking Lot Violation
042. Public Display of Affection
043. Other Violation of School Policies
Tobacco Violation
065. Tobacco – Distribute or Share*
066. Tobacco–Use or Possession*
067. Tobacco – Sale*
Vandalism or Criminal Damage
068. Graffiti or Tagging
069. Vandalism Personal Property
070. Vandalism School Property
School Threat
044. Bomb Threat**
045. Chemical/Biological Threat**
046. Fire Alarm Misuse **
047. Other Threat: __________
Weapons & Dangerous Items
071. Dangerous Items*
072. Firearms*
073. Simulated Firearm
074. Other Weapons:
_____________
ACTION TAKEN (Check all boxes that apply)
Completed in One Day
Confiscation of Contraband
Drug Test
Parent Conference
Parent Notification
Referred to outside agency
Student Conference
Student Verbal Apology
Student Written Apology
Warning
Withdrawal from School
Completed in One or More Days
Behavior Contract
Behavior Intervention Group: Anger
Behavior Intervention Group: Drug
Behavior Intervention Group: Other
Behavior Intervention Plan
Community Service
Detention
Functional Behavioral Assessment
Meeting with School Counselor
Peer Mediation
Privileges Suspended
Completed in One or More Days
Restitution
Saturday School
Teen Court
Threat Assessment
Work Detail
Within Due Process
Appeal Review
Disciplinary Hearing
IEP Team Meeting
Manifestation Determination
Placement Review Committee
Board Review
Removal
Expulsion w/Services
Expulsion w/out Services
Long Term w/Services
Long Term w/out Services
Short Term w/Services
Short Term w/out Services
In School Suspension
Alternative Education Setting
Reassignment to Different Class
Reassignment other SchoolTUHSD
Law Enforcement Contacted Report No: _____________
PARENT CONTACT BY ADMINISTRATION (Check all boxes that apply)
C Conference
H Home Visit
L Letter
E Email
P Phone & Letter
S Student Conference
T Telephone: Number Called _______________________
V Voice/Left Message
COMMENTS
DETENTION DATE
DURATION
SUSPENSION DATES
DURATION
RETURN TO SCHOOL
ADMINISTRATOR SIGNATURE_____________________________________ ADMINISTRATIVE ACTION DATE___________
Revised – 2/10/2012
White – Administration
*Violation reported to Arizona Department of Education (ADE)
Pink – Student
** Reported to local law enforcement and ADE
Yellow – Parent/Guardian