Discipline Referral Form (Rev.

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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
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