Page 10 - Restorative Practices Implementation Guide - Introductory Version

Appendix
Discipline Referral Form
RJDisciplineReferral Form
STuDenT PROFil e
Student’s_Name__________________________________ _ _M_/_F_ Date___________________________________________________ Grade_ Teacher__________________________________________________ Type of resets used: ____________________________PleasegiveanestimatedtimewhenyouareavailableforRJconferencew/student: __________
Time:_(please_check)_ __8-9_am_ Location:_(please_check)_____ __Classroom_
_ __9-10am_
__Restroom_ __Specials_
__10-11_am_ __11-12pm_
__12-1pm_
__Office_ __Other
__1-2pm_ __2-3pm_ __3-4pm_ __Arrival/Departure_
___inappropriate_language/gestures ___refusal_to_work/participate_ ___property_damage ___other_(please_describe) ___tardy_or_truant
_
__Outdoor_Recess_
PROBl eM BeHAviOR
__Hallway_ __Assembly_Room_
__Indoor_Recess_ __Cafeteria_
___disruption_
___harassment_/bullying_
___threats_
___lying/cheating_
___dress_code_violation_ ___other______________________________
___insubordination/defiance_ ___verbal_abuse_ ___fighting/physical_aggression_ ___stealing_ ___sexual_harassment_
brief_description_of_behavior:_
cHeck THeAPPROPRiATeBOx
OTHeRS invOlveD_ ___none_
___staff_
___substitute_teacher_
___unknown_ ___other_student(s)—please_name_below:_
RJ Staff AcTiOnS
___conference_w/_student_ ___communication_w/_parent_ _______ Classroom contract _______ Behavior contract ________Cleaning contract ________ Lunch detention ___other-please_specify:_
POSSiBl e TeAcHeR RecOMMenDATiOnS
TeAcHeR AcTiOnS_
___conference_w/_student_
___communication_w/_parent_
___in-class_time-out_
___think_sheet_
___privilege_loss_
___out_of_class_time-out
___apology_restitution_ ___other-please_specify: ___parent_contact_form_
___corrective_activity_restitution__
___home/school_plan_ _ ___written_contract_
___other—please_specify:_
___Reset student ___keep_for______minutes ___RJ conference ___contact_parent
_ _ _ _ _ _ _
___apology_ ___corrective_activity_RJ essays
Date_entered_into_Database
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