Back-up not in agenda book - Seminole County Schools

Seminole County Public Schools, FloridaDISCIPLINE REFERRALFlorida Department of EducationSTUDENT NAME: ______________________________ SCHOOL NAME/#: ____________________ GRADE: _________OFFICE USE ONLYINCIDENT #: ___________________ STUDENT #: ______________ ESE: ____________ADMINISTRATIVE USE ONLYREFERRED BY: ______________________ LOCATION: ___________________ BUS #: ________________REFERRAL DATE: ________ INCIDENT DATE: ___________________ TIME: ________ PERIOD: ________DESCRIPTION: __________________________________________________________________________________________________________________________________________________________________________________________________________________________School environmental safety incident report must be reported to law enforcement:__ Alcohol __Drug Use/Possess Exc. Alcohol __ Sexual Battery__ Arson __ Homicide __ Sexual Offenses (Other)__ Battery __ Kidnapping __ Threat/Intimidation__ Breaking and Entering/Burglary __ Other Major __ Trespassing__ Disruption on Campus/Major __ Robbery __ Vandalism__ Drug Sale/Dist Exc. Alcohol __ Larceny/Theft __ WeaponMay not need to report to LawEnforcement:__ Bullying __S __U__Harassment __S __ U__ Fighting__ Sexual Harassment_ _TobaccoRELATED ELEMENTS (Please check all that apply to SESIR Incidents)__ Alcohol __ Bullying __ Drugs: __ M - Marijuana/Hashish __ O – Other Illicit Drugs__ Gang __ Hate Crime __ Injury __Harassment__ Weapon: __ Other (Describe) _________________________________ __ Knife__ Firearm: __ Handgun __ Rifle/Shotgun __ Other __ Unknown __ # of Weapons __Student in possession of weapon: __ Yes __ NoParent Contact__ Parent Notification: __ Personal Contact __ Phone Message __ Written CommunicationName of Parent/Guardian: _______________________________________________Phone (H/W/C): __________________________Notes: _____________________________________________________________________________________________________________ADMINISTRATIVE DISPOSITION__ Alternative Placement __ Expulsion with services recommended __ Out –Of-School Suspension__ Behavioral Contract __ Expulsion without services recommended __ Temp. Class Placement__ Bus Expulsion__ In-School SuspensionNumber 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 manifestation meetingis 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.DESCRIPTION: _________________________________________________________________________Parent Signature: ______________________________Principal Signature: ___________________SCPS 835DOE (Rev. 5/14/10) FL White Copy – School Yellow Copy – Teacher/Staff Pink Copy – Student/Parent Gold - Other38Page 573