HTML Preview School Behavior Incident Report page number 1.
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 acvies, and of subsequent disciplinary acon taken by school ocials. Because this or other incidents may jeopardize the
safety, well-being or educaon of other students, parents are urged to discuss the incident and possible implicaons with the student to prevent further occurrences.
Name of Student Phone Grade/Secon
Name of Teacher/Sta Teacher/Sta/Locaon
Name of Principal School
Check One: Regular Educaon 504 Special Educaon Date of Incident Time Locaon
Time Code: ___________
01 Before School on Grounds, 02 During Class, 03 Between Classes, 04 Aer Normal School Hours & Supervised, 05 To / From School, 06 At Bus Stop or Transfer
Staon, 07 During School Extracurricular/Assembly Event, 08 Recess, Club, Free Time, 09 Homeroom, 10 Breakfast /Lunch
Locaon Code: ________
01 Classroom, 02 Restroom, 03 Lunchroom, 04 Hallway, 05 Playground, 07 At Bus Stop or Transfer Staon, 08 Parking Lot, 09 Locker Room, 10 Cell Phone,
11 Internet, 12 To or From School, 13 School Sponsored Event, 14 Home, 98 Osite 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 pracces
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.
Insgates or parcipates in ghts while under
school supervision
17.
Violates trac and safety regulaons
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 oense
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 Violaon
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 cumulave
behavioral referral(s). I have taken the following acon(s):
011 Referred to Oce 012 Referred to Counselor 013 Referred to Social Worker 014 Referred to SBLC 018 Secondary Referral (PBIS)
019 Terary Referral (PBIS) 022 Therapeuc Removal 025 Intervenon Room 080 Assigned Remedial Work
120 Student Conference 140 Student Reprimand 160 Loss of Privileges 030 Restorave Pracces Implemented
173 Conference with Parents or Guardians 175 Conference with Principal 999 Other Acon
Contact Parent/Guardian Date: Time: Phone Call Leer 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 cumulave
behavioral referral(s). I have taken the following acon(s):
000
No Acon– only use if no reportable acon was taken
012
Referred to Counselor
043
Aer School Detenon 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 Commiee (SBLC)
045
Weekend Detenon from to
006
Suspension Alternave Site from to
016
Court Referral Date
999
Other Acon(s):
120
Student Conference Date:
180
Corporal Punishment (if checked, complete “Corporal Punishment” Incidence Checklist)
020
TOR (Time Out Room)
040
In School Detenon from to
002
Suspension Out of School from to
001
013
Referral to Social Worker
030
Restorave Pracces 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 Leer 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 subming this referral.
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