School Behavior Incident Report

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I have taken the following action(s): 000  012  043  004  017  080  140  175  No Action– only use if no reportable action was taken Referred to Counselor After School Detention from to Suspension In School from to Enforcement Referral (Arrest Resulted Y N) Assigned Remedial Work Student Reprimand Conference w/ Principal on: Circle Yes or No: Perpetrator: Serious Bodily Injury Y N Y N Contact Parent/Guardian Date: SIS Primary Infraction/Reason Code Entered: 160  Loss of Privileges 014  Referred to School Building Level Committee (SBLC) 045  Weekend Detention from to 006  016  999  120  180  1st 2nd 020  040  002  001  013  030  173  3rd 4th 5th (circle one) or other cumulative TOR (Time Out Room) In School Detention from to Suspension Out of School from to Expulsion Recommendation Referral to Social Worker Restorative Practices Implemented Conference w/ Parents or Guardians on: Suspension Alternative Site from to Court Referral Date Other Action(s): Student Conference Date: Corporal Punishment (if checked, complete “Corporal Punishment” Incidence Checklist) Medical Treatment Y N Time: Victim: Serious Bodily Injury Y N  Phone Call  Letter Medical Treatment Y N  Conference Date: Time: Signature of Principal: Date: COMMENTS BY STUDENT AND/OR PARENT/GUARDIAN: Signature of Student: Check appropriate blocks as copies of the document are supplied: Signature of Parent/Guardian:  Parent/Guardian  School’s Pupil File Current Date:  Employee Filing this Report  Principal NOTE: The principal shall return a completed copy of this form to the staff member who initiated the referral within 48 hours (excluding non-work days) of the time it was submitted to the principal..

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