Page 84 - FY21_LawsonAcademy_FacultyHandbook
P. 84
EXHIBIT G: INCIDENT REPORT/DISCIPLINE REFERRAL
INCIDENT REPORT/DISCIPLINE REFERRAL
STUDENT GRADE DATE
REFERRING TEACHER TIME
1 2 3 Minor Major Motivation
Disruptive Defiance/Disrespect AODA Peer Attention
Inappropriate Language Abusive/Inapprop. Language Vandalism Adult Attention
Non-Compliance/Disrespect Fight/Physical Aggression Weapons Avoid Peers
Physical Contact Harassment: physical, verbal Lying/Cheating Avoid Adults
Property Misuse Disruption Theft Avoid Work
Tardy Tardy/Truancy Other: Obtain Items
Other: Don’t Know
LOCATION:
Class Hall Playground Cafeteria Bathroom Bus Admin Office Other
OTHERS INVOLVED:
None Peers Teacher Staff Sub Other:
INCIDENT REPORT
ACTIONS/CONSEQUENCES:
Class Removal Parent Meeting Requested
Intervention to Process Incident Pupil Service/Counselor Referral
AM/Snack/Noon Detention Juvenile Intake/ Police Referral
After-School Detention Other:
Alternate Placement Room Time: Parent Notified Delivery/Phone/Mail
Out-of-School Suspension
FOLLOW UP AGREEMENT
1. What rule did you break? ____ Respect Others ____ Respect Self ____Respect Environment
2. What did I want? ___ attention from others ___ avoid doing work ___ challenge authority ___ revenge
___ to be in control ___ cause problems because I felt miserable
___ to be sent home ___ to cause problems because they don’t like me
3. Did you get what you wanted? ____ yes ____ no
4. How can you get what you want in a positive way? I will (see #1)___________________________________________
by
Student Signature:__________________________ Principal/Staff Date
Copy to: ____ parent, ____advisor/teacher, ____ counselor, ____ Principal, ____other
Page 76
