Back-up not in agenda book - Seminole County Schools

Seminole County Public Schools, FloridaDISCIPLINE REFERRALSTUDENT NAME: ___________________________________________SCHOOL NAME/#: ________________ GRADE: ______OFFICE USE ONLYINCIDENT #: _________________________ STUDENT #: _______________________ ESE: _______TEACHER/STAFFREFERRED BY: _________________ LOCATION: _________ BUS #: _______REFERRAL DATE: ______________ INCIDENT DATE: _______ TIME: ______ PERIOD: ___DESCRIPTION: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________TEACHER/STAFF DISPOSITION (Prior to current referral)___Conference w/Student ___Parent Contact (Date: __/__/__) (Date: ___/___/___) ___ Parent Conference (Date: __/__/___)___ Referral to Guidance ___Class Detention (Date: ___/___/___) (Date: ___/___/___) ___ Other: _______________ADMINISTRATIVE USE ONLYINFRACTION: _________________________________________________________________________Name of InfractionRtI (Response to Intervention)__ Avoid Adult __ Avoid Peers __ Avoid Task/Attn. __ Unknown__ Obtain Adult Attn. __ Obtain Items/Attn __ Obtain Peer AttnPARENT CONTACT___ Parent Notification ___Personal Contact ___Phone Message ___Written CommunicationParent/Guardian Name: _________________________Phone (H/W/C): _______________________________Notes: ________________________________________________________________________________________________________________________________________________________________________________________________________ADMINISTRATIVE DISPOSITION___Alternative Educational Assignment ___Detention ___Expulsion without services recommended___Banned from specified school ___Formal Referral to Law Enforcement ___Restitutionfunction: ____________________ ___Guidance Referral ___Sat. School___Behavioral Contract ___In-School Suspension ___Temp. Class Placement___Bus Expulsion ___Out-of-School Suspension ___Verbal Reprimand___Bus Probation ___Parent Conference ___Wed. School___Bus Suspension ___Parking Revoked ___Work Detail___Confiscation___Expulsion with services recommendedNumber of Days: ________ Beginning Date: __________ Ending Date: __________ Return Date: _______ESE STUDENT: If the student has received more than ten cumulative days of suspension during the current school year a Manifestationmeeting is required within ten school days, and a copy of the IDEA Procedural Safeguards must be attached to this form____ Please check, if a Manifestation meeting is required for this student.HONOR CODE VIOLATION: ___1 st Offense ___2 nd Offense ___3 rd OffenseCITIZENSHIP STANDARDS FOR PARTICIPATION___On Campus Violation Level: ______ Sport/Activity: ________________________________________Off Campus Violation Level: ______ #Events to be Missed: _______________________________Parent Signature: _____________________________________Student Signature: _____________________________________Administrator Signature: ________________________________________Date: ________________________White Copy – School Yellow Copy – Teacher/Staff Pink Copy – Student/Parent Gold - Other(Rev 5/14/10)37Page 572