Please email this referral to the appropriate person indicated below:
12 th Grade: Blythe Young | 11 th Grade: Sechin Tower | 10 th Grade: Shaun Monaghan | 9 th Grade: Michelle Renee
Attendance-Related: Kristina Monten
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Student Name:
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| Grade:
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| Date:
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| Time/Period:
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Referring Staff:
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Location
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Classroom Hallway Restroom Commons/Annex Gym Other:
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Select the interventions used (a minimum of 3) prior to referring for MINOR incidents.
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Verbal cue/Redirection Private conversation with student Parent Communication Lunch Duty
Parent Conference Referral to Counselor Referral to Success Coordinator Attendance/Behavior Contract
Other:
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Minor
| Major
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Disruption of student learning
| Abusive/Aggressive Language
| Lewd Behavior
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Failure to follow instructions
| Cheating
| Lewd language
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Inappropriate language
| Significant Disruption of learning environment
| Property Damage/Vandalism
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Non-threatening physical contact
| Fighting/Physical Aggression
| Refusal to Identify
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Property Destruction ( < $50 damage)
| Harassment/Bullying (over time)
| Verbal defiance to directions
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Truancy
| Illegal Substances
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| Repetitive Minor Infractions - 3+ referrals over a period of month
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Describe the behavior and incident. Be specific .
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Student was notified of this referral on (date).
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