Disciplinary Referral Form Disciplinary Referral Form - AWS
Disciplinary Referral Form Please be sure to complete top section and “Steps Taken Prior”
Submit only one per student - click on appropriate recipient
Heather Fitzgibbons
Geoff Lyons
Student Name:
Date of Incident:
Student ID#:
Time of Incident:
Student Grade:
Location of Incident:
Submitted by:
Devin Quinlan
(Time of day)
Faculty / Staff
Assistant Principal Referral Major Behavioral Violation(s)
Heather Fitzgibbons Geoff Lyons
Weapons possession, threat to use or actual use Drug / alcohol / Tobacco violation Serious physical acts of violence Serious verbal aggression, harassment or threat Gross disrespect / Insubordination
Dean of Students Referral
Grades 9 / 12 Grades 10 / 11
Serious damage to property Theft Cheating / plagiarism Other (describe)
Devin Quinlan
Grades 9 - 12
Behavioral Violation(s) Cellphone issue
Use of technology violation
Not following schedule
Failure to comply with reasonable request/expectation
Leaving campus without permission
Other
Leaving without permission Disrespect for the rights of others
Excessive absences
Steps Taken by Faculty / Staff Prior to this Referral: Conference with the student to develop a solution which emphasizes personal responsibility Use of school-wide language with student outlining, “Your Job - My Job” Review social contract for classroom expectations with student Phone call to parent / guardian Conference with parent(s) / guardian(s)
Date of call Date of conference
Consulted with then student’s Guidance Counselor or Case Manager Referral to Educational Support Team (EST)
Name of Contact
Actions Taken as a Result of This Referral MEETING with Dean of Students and a phone call to parent / guardian STUDENT SUCCESS PLAN RESTORATIVE CONFERENCE INTERNAL SCHOOL SUPPORT(ISS) assigned for:
Date
Following this ISS placement, students may be required to be part of a re-entry meeting. If required, this meeting will be with: Name of Contact
DETENTION has been assigned for:
Date
Detentions are assigned Tuesday and Thursdays, from 2:50pm - 3:50pm (unless otherwise stated above)
ADMINISTRATIVE CONFERENCE (this includes the student and parent/guardian). An Administrative Conference has been scheduled for:
Date/Time
OUT OF SCHOOL SUSPENSION(OSS) - number of days suspended: - dates suspended:
# of days Date
REFERRAL TO HOME SCHOOL COORDINATOR: REFERRAL TO SUBSTANCE ABUSE CLINICIAN: This matter referred to:
School Resource Officer
Signature of Administrator / Designee: Teacher / Staff Comments (optional)
Guidance Counselor
Case Manager
CHART OF CODES (FOR OFFICE USE ONLY ) ABP
Aggressive Behavior Physical
ABV
Aggressive Behavior Verbal
BA
Battery
CP
Cell Phone Violation
DO
Disorderly Conduct
DT
Detention Violation
DV
Dress Code Violation
FT
Fighting
GD
Gross Disrespect / Insubordination
IL
Inappropriate Language
IM
Inappropriate Materials use/possession
LCWP
Left Class Without Permission
LWOP
Left School Without Permission cut classes
NFD
Not Following Directions
OC
Off campus
PC
Parking on campus
PL
Plagiarism/Cheating
SUB
Substance Violation alcohol, drug
TDC
Tardy to Class
TDS
Tardy to school
THF
Theft
THR
Threatening/Intimidating Behavior
TOB
Tobacco Violation
TR
Truant
TV
Technology Violation
VN
Vandalism or Property Damage
WP
Weapons
Submit only one per student - click on appropriate recipient
Heather Fitzgibbons
Geoff Lyons
Student Name:
Date of Incident:
Student ID#:
Time of Incident:
Student Grade:
Location of Incident:
Submitted by:
Devin Quinlan
(Time of day)
Faculty / Staff
Assistant Principal Referral Major Behavioral Violation(s)
Heather Fitzgibbons Geoff Lyons
Weapons possession, threat to use or actual use Drug / alcohol / Tobacco violation Serious physical acts of violence Serious verbal aggression, harassment or threat Gross disrespect / Insubordination
Dean of Students Referral
Grades 9 / 12 Grades 10 / 11
Serious damage to property Theft Cheating / plagiarism Other (describe)
Devin Quinlan
Grades 9 - 12
Behavioral Violation(s) Cellphone issue
Use of technology violation
Not following schedule
Failure to comply with reasonable request/expectation
Leaving campus without permission
Other
Leaving without permission Disrespect for the rights of others
Excessive absences
Steps Taken by Faculty / Staff Prior to this Referral: Conference with the student to develop a solution which emphasizes personal responsibility Use of school-wide language with student outlining, “Your Job - My Job” Review social contract for classroom expectations with student Phone call to parent / guardian Conference with parent(s) / guardian(s)
Date of call Date of conference
Consulted with then student’s Guidance Counselor or Case Manager Referral to Educational Support Team (EST)
Name of Contact
Actions Taken as a Result of This Referral MEETING with Dean of Students and a phone call to parent / guardian STUDENT SUCCESS PLAN RESTORATIVE CONFERENCE INTERNAL SCHOOL SUPPORT(ISS) assigned for:
Date
Following this ISS placement, students may be required to be part of a re-entry meeting. If required, this meeting will be with: Name of Contact
DETENTION has been assigned for:
Date
Detentions are assigned Tuesday and Thursdays, from 2:50pm - 3:50pm (unless otherwise stated above)
ADMINISTRATIVE CONFERENCE (this includes the student and parent/guardian). An Administrative Conference has been scheduled for:
Date/Time
OUT OF SCHOOL SUSPENSION(OSS) - number of days suspended: - dates suspended:
# of days Date
REFERRAL TO HOME SCHOOL COORDINATOR: REFERRAL TO SUBSTANCE ABUSE CLINICIAN: This matter referred to:
School Resource Officer
Signature of Administrator / Designee: Teacher / Staff Comments (optional)
Guidance Counselor
Case Manager
CHART OF CODES (FOR OFFICE USE ONLY ) ABP
Aggressive Behavior Physical
ABV
Aggressive Behavior Verbal
BA
Battery
CP
Cell Phone Violation
DO
Disorderly Conduct
DT
Detention Violation
DV
Dress Code Violation
FT
Fighting
GD
Gross Disrespect / Insubordination
IL
Inappropriate Language
IM
Inappropriate Materials use/possession
LCWP
Left Class Without Permission
LWOP
Left School Without Permission cut classes
NFD
Not Following Directions
OC
Off campus
PC
Parking on campus
PL
Plagiarism/Cheating
SUB
Substance Violation alcohol, drug
TDC
Tardy to Class
TDS
Tardy to school
THF
Theft
THR
Threatening/Intimidating Behavior
TOB
Tobacco Violation
TR
Truant
TV
Technology Violation
VN
Vandalism or Property Damage
WP
Weapons
