Expected Behaviors in Safe and Supportive Schools: Discipline Referral Form (Rev. 3/16/2016). Person Originating the Referral: _________________________________________ INCIDENT INFORMATION Date ___/___/_____ Time ___:___ am/pm Tardiness Or Truancy Failure To Obey Rules/ Authority Serious Bodily Injury: Yes No Number(s) involved ____ Incident Category Disrespectful/ Inappropriate Conduct Legal Concerns Aggressive Conduct Illegal Drugs/ Substances Weapons Location Athletic Field Auditorium Bathroom/ Restroom Bus Loading Zone Bus Stop Bus Cafeteria Classroom Computer Lab Commons/ Common Areas Gym Hall/ Breeze Way Locker Room Library Office Playground Parking Lot Shop Area Special Event/ Assembly/ Field Trip Stairwell COMPLETE THE FOLLOWING INFORMATION FOR EACH PERSON INVOLVED IN THE INCIDENT Use separate sheets for each person. All sheets completed for a single incident should be stapled together. Person Number __ Name: ________________________________ Role? Peer Staff Student Substitute Other Behaviors Exhibited You may indicate up to THREE behaviors for each person involved as follows: P = Primary (Most Severe) Behavior S = Secondary Behavior A = Additional Behavior ____ Involved as non-offender or target ____ Leaving School Without Permission ____ Threat of Injury/Assault Against An Employee or ____ Cheating ____ Physical Fight Without Injury A Student Level 1 ____ Deceit ____ Possession of Imitation Weapon ____ Trespassing ____ Disruptive/Disrespectful Conduct ____ Possession of Knife not meeting Dangerous Weapon ____ Harassment/Bullying/Intimidation ____ Failure to Serve Detention Definition (West Virginia Code §61-7-2) ____ Imitation Drugs: Possession, Use, Distribution ____ Falsifying Identity ____ Profane Language/ Obscene Gesture/ Indecent Act or Sale ____ Inappropriate Appearance Toward An Employee or A Student ____ Inhalant Abuse Level 2 ____ Inappropriate Display of Affection ____ Technology Misuse ____ Possession/Use of Substance Containing Level 3 ____ Inappropriate Language ____ Battery Against a Student Tobacco and/or Nicotine Level 3 ____ Possession of Inappropriate Personal ____ Defacing School Property/ Vandalism ____ Battery Against a School Employee Level 4 Property ____ False Fire Alarm ____ Felony ____ Skipping Class ____ Fraud/Forgery ____ Possession and/or Use of Dangerous Weapon ____ Tardiness ____ Gambling ____ Illegal Substance Related Behaviors (Check ____ Vehicle Parking Violation which below): Level 1 ____ Hazing ____ Gang Related Activity ____ Improper or Negligent Operation of a Motor Vehicle ____ Use/Possession of Illicit Drugs Level 2 ____ Habitual Violation of School Rules or ____ Larceny ____ Use/Possession of Alcohol Policies ____ Sexual Misconduct ____ Sale of a Narcotic ____ Insubordination Was Restraint Required for this Person? Yes No This offense reflects a need for intervention for which of the School and Community Social Skill Standards? Self-awareness and Self-management Social-awareness and Interpersonal Skills Decision-making Skills and Responsible Behaviors Comments: Interventions You may indicate up to TWO Interventions each person as follows: P = Primary Action S = Secondary Action ____ No action warranted ____ Referral to medical or mental health service ____ Immediate exclusion by teacher from the ____ Administrator/student conference or ____ Referral to support staff/ counseling/ other classroom reprimand therapeutic services ____ Voluntary weekend detention ____ Teacher/student conference or ____ Referral to a tobacco cessation program ____ In-school suspension reprimand ____ Change in the student's class schedule ____ Law enforcement notification ____ Administrator and teacher____ School service assignment ____ Placement of student w/disability to Interim parent/guardian conference ____ Confiscation of inappropriate item Alt. Ed. by school personnel ____ Teacher parent contact ____ Revocation of privileges ____ Placement of student w/ disability to Interim ____ Academic sanctions ____ Restitution/restoration Alt. Ed. by WVDE Due Process Hearing ____ Counseling referrals and conference to ____ Detention – lunch Officer support staff or agencies ____ Detention - before school ____ Placement of student to Alt. Ed. Setting ____ Daily/weekly progress reports ____ Detention - after school ____ Out-of-school suspension ____ Behavioral contracts ____ Denial of participation in class and/or school activities ____ Recommended Expulsion ____ Referral to IEP Team Primary: Start Date: ___/___/_____ End Date ___/___/_____ Secondary: Start Date: ___/___/_____ End Date ___/___/_____ Duration: _________ Days Duration: _________ Days Comments