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Please Enter Student Id:

Please Enter Staff Id:

Name Of School:

Discipline Referral Form

Staff Info:

Student Info:

Parent/Guardian Contacted? YesNoUnable

Time of Incident:

Location of Incident:

Check any applicable to Incident. (If other, explain on blank line)

Verbal (Inappropriate language, bullying/hurtful words, etc.)

Physical (Destruction of property, pushing, etc.)

Refusal to follow teacher/staff’s directives

Leaving school property without permission.

Stealing or taking of others property.

Fighting/assault with another student and/or staff.

Possession of a controlled drug/substance/alcohol.

Possession of weapon. (Knife, blunt objects, etc.)

Other:

Describe Incident:

Number Of Referral:

First Referral

Second Referral

Third Referral

STAFF ACTION TAKEN (Include date and time on blank line.)

Removal of privileges

Kept Student in for detention

Sent to the office.

Referral for Special Education.

Referred to JCY Social Counsellor or Wellbeing Worker.

ADMINISTRATION ACTION REQUIRED: Yes No

If administration action is required, please attach intervention logs. Thanks!

Additional Comments or concerns:

Signature:

Date: