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In accordance with R. S. 17:416(A) the purpose of this report is to inform parents/guardians of a behavior incident on the school campus, in the classroom, cafeteria, gymnasium,
auditorium, elsewhere at the school or during school-related acvies, and of subsequent disciplinary acon taken by school ocials. Because this or other incidents may jeopardize the
safety, well-being or educaon of other students, parents are urged to discuss the incident and possible implicaons with the student to prevent further occurrences.
Name of Student Phone Grade/Secon
Name of Teacher/Sta Teacher/Sta/Locaon
Name of Principal School
Check One: Regular Educaon 504 Special Educaon Date of Incident Time Locaon
Time Code: ___________
01 Before School on Grounds, 02 During Class, 03 Between Classes, 04 Aer Normal School Hours & Supervised, 05 To / From School, 06 At Bus Stop or Transfer
Staon, 07 During School Extracurricular/Assembly Event, 08 Recess, Club, Free Time, 09 Homeroom, 10 Breakfast /Lunch
Locaon Code: ________
01 Classroom, 02 Restroom, 03 Lunchroom, 04 Hallway, 05 Playground, 07 At Bus Stop or Transfer Staon, 08 Parking Lot, 09 Locker Room, 10 Cell Phone,
11 Internet, 12 To or From School, 13 School Sponsored Event, 14 Home, 98 Osite Program, 99 Other
INFRACTION / REASON CODES (Check all that apply)
01.
Willful disobedience
02.
Treats an authority with disrespect
03.
Makes an unfounded charge against authority
04.
Uses profane and/or obscene language
05.
Commits immoral or vicious pracces
06.
Conduct or habits injurious to his/her associates
08.
Uses or possesses tobacco, lighter or matches
09.
Uses or possesses alcoholic beverages
10.
Disturbs the school or habitually violates any rule
11.
Cuts, defaces, or injures any part of public school
buildings/vandalism
12.
Writes profane and/or obscene language or draws
obscene pictures
15.
Throws missiles liable to injure others
16.
Insgates or parcipates in ghts while under
school supervision
17.
Violates trac and safety regulaons
18.
Leaves school premises or classroom without permission
19.
Is habitually tardy and/or absent
20.
Takes another’s property or possessions without
permission
21.
Commits any other serious oense
35.
Bullying/Harrassment (*complete Bullying Form)
36.
Cyber Bullying (*complete Bullying Form)
38.
Forgery
39.
Gambling
42.
Unauthorized use of Technology
43.
Improper dress
44.
Academic dishonesty
45.
Trespassing Violaon
46.
Failure to Serve Assigned Consequence
47.
Misusing Internet/Violates electronic/technology policy
49.
False Report
REMARKS/DESCRIPTION OF INCIDENT:

The student named above is hereby reported for inappropriate behavior as indicated in this report. This is the student’s 1
st
2
nd
3
rd
4
th
5
th
(circle one) or other cumulave
behavioral referral(s). I have taken the following acon(s):
011 Referred to Oce 012 Referred to Counselor 013 Referred to Social Worker 014 Referred to SBLC 018 Secondary Referral (PBIS)
019 Terary Referral (PBIS) 022 Therapeuc Removal 025 Intervenon Room 080 Assigned Remedial Work
120 Student Conference 140 Student Reprimand 160 Loss of Privileges 030 Restorave Pracces Implemented
173 Conference with Parents or Guardians 175 Conference with Principal 999 Other Acon
 Contact Parent/Guardian Date: Time: Phone Call Leer Conference Date: Time:

Signature of School Employee: Date:

The student named above is hereby reported for inappropriate behavior as indicated in this report. This is the student’s 1
st
2
nd
3
rd
4
th
5
th
(circle one) or other cumulave
behavioral referral(s). I have taken the following acon(s):
000
No Acon– only use if no reportable acon was taken
012
Referred to Counselor
043
Aer School Detenon from to
004
Suspension In School from to
017
Enforcement Referral (Arrest Resulted Y N)
080
Assigned Remedial Work
140
Student Reprimand
175
Conference w/ Principal on:
160
Loss of Privileges
014
Referred to School Building Level Commiee (SBLC)
045
Weekend Detenon from to
006
Suspension Alternave Site from to
016
Court Referral Date
999
Other Acon(s):
120
Student Conference Date:
180
Corporal Punishment (if checked, complete “Corporal Punishment” Incidence Checklist)
020
TOR (Time Out Room)
040
In School Detenon from to
002
Suspension Out of School from to
001

013
Referral to Social Worker
030
Restorave Pracces Implemented
173
Conference w/ Parents or Guardians on:
Circle Yes or No:  Serious Bodily Injury Y N Medical Treatment Y N  Serious Bodily Injury Y N Medical Treatment Y N
 Contact Parent/Guardian Date: Time: Phone Call Leer Conference Date: Time:
SIS Primary Infracon/Reason Code Entered: Signature of Principal: Date:

Signature of Student: Signature of Parent/Guardian: Current Date:
Check appropriate blocks as copies of the document are supplied: Parent/Guardian School’s Pupil File Employee Filing this Report Principal


 Provide copies of all documents related to the behavior of the student named above and prepared by the employee subming this referral.
10/31/


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