<p> ™ Documentation Project</p><p>Referral Form Examples Version 4.3 June 2009 Anne W. Todd, Rob Horner, Celeste Rossetto Dickey</p><p>Intended Audience Referral form examples are for School Administrators, school teams and SWIS Facilitators to use as a guide for developing an office discipline referral form.</p><p>Description</p><p>The three available referral form examples are each compatible with SWIS. Each example is formatted differently, in size of paper, actual categories on the form, extra information options, and the order of the information to be recorded. Example A</p><p>SWISTM OFFICE DISCIPLINE REFERRAL FORM</p><p>Student(s) ______Referring Staff ______Grade Level ____ Date ______Time ___</p><p>Location</p><p>Classroom Cafeteria Bus loading zone Other ______</p><p>Playground Bathroom/restroom Parking lot</p><p>Commons/common area Gym On bus</p><p>Hallway/ breezeway Library Special event/assembly/ field trip  East  West  North  South Problem Behaviors (check the most intrusive)</p><p>MINOR MAJOR Tardy Off School  Inappropriate lang. Abusive lang./ inapprop. lang Location Skip class Physical contact Fighting/ physical aggression Vandalism Forgery/ theft Defiance/disrespect/ non-compliance Defiance/disrespect/insubordina  Property damage tion/non-compliant Dress code Disruption violation Bomb threat Harassment/ tease/ taunt  Dress Code ability  religious  racial Lying/cheating Arson gender  sexual Technology violation Tobacco Weapons Disruption Property misuse Alcohol/drugs Other ______Inappropriate Display of Tardy Affection Combustibles Technology Violation Other ______</p><p>Possible Motivation </p><p>Obtain peer attention  Avoid tasks/activities  Don’t know</p><p>Obtain adult attention  Avoid peer(s)  Other ______</p><p>Obtain items/ activities  Avoid adult(s) Others Involved</p><p>None  Peers  Staff  Teacher  Substitute  Unknown Other ______Administrative Decision </p><p>Time in office  Detention  Saturday School  In-school suspension Days ______</p><p>Loss of privilege  Parent contact  Individualized instruction  Out-of-school suspension Days _____</p><p>Conference with student  Other ______Comments: Example B</p><p>Office Referral Form</p><p>Name: ______Location Date: ______Time: ______ Playground  Library Teacher: ______ Cafeteria  Bathroom  A  B  C Grade: K 1 2 3 4 5 6 7 8  Hallway  Arrival/Dismissal Referring Staff: ______ Classroom  Other ______</p><p>Minor Problem Major Problem Behavior Possible Motivation Behavior  Inappropriate language  Abusive language  Obtain peer attention  Physical contact  Fighting/ Physical  Obtain adult attention  Defiance aggression  Obtain items/activities  Disruption  Defiance/Disrespect  Avoid Peer(s)  Dress Code  Harassment/Bullying  Avoid Adult  Property misuse  Dress Code  Avoid task or activity  Tardy  Inappropriate Display Aff.  Don’t know  Electronic Violation  Electronic Violation  Other ______ Other ______ Lying/ Cheating  Skipping class  Other ______Administrative Decision  Loss of privilege  Individualized instruction  Time in office  In-school suspension (____hours/ days)  Conference with student  Out of school suspension (_____ days)  Parent Contact  Other ______</p><p>Others involved in incident:  None  Peers  Staff  Teacher  Substitute  Unknown  Other Other comments: ______</p><p> I need to talk to the students’ teacher  I need to talk to the administrator</p><p>Parent Signature: ______Date: ______All minors are filed with classroom teacher. Three minors equal a major. All majors require administrator consequence, parent contact, and signature.</p><p>Example C</p><p>Office Discipline Referral Form</p><p>Name: ______Grade: _____ Date: _____ Referring Person: ______Time: ______</p><p>Others involved:  no one peers teacher staff substitute  unknown </p><p>Issue of Concern Location Possible Motivation Major Problem Behaviors  Abusive lang  Playground Attention from peer(s)  Fighting/physical agg  Cafeteria  Attention from adult(s)  Harassment  Hall  Avoid peer(s)  Defiance/Disrespect  Bathroom  Avoid adult(s)  Tardy  Entrance  Avoid work  Dress code  Classroom  Obtain item(s)  Electronic violation  Commons  Don’t know Disruption  Other ______ Other ______Other ______</p><p>What happened?______</p><p>______Consequences  time out/detention  loss of privilege______ conference w/ student  in-school suspension days ______ parent contact  out-of-school suspension days ______ other ______</p><p>Follow up Agreement Name: ______Date: ______1. What rule(s) did you break? (Circle) Be Safe Be Respectful Be Responsible</p><p>2. What will you do differently next time? </p><p>Student signature: ______</p><p>Adult signature(s): ______</p>