Office Referral Form - SCHOOLinSITES



Edisto Elementary School

Office Referral Form

Name:      

Date:       Time:      

Teacher:       Grade:      

Referring Staff:

Date Of Last Contact With Parent:

Date Of Guidance Referral:

Location: Playground Library Cafeteria Bathroom Hallway

Classroom Arrival/Dismissal Other      

|Problem Behavior |Possible Motivation |Administrative Decision |

|Minor | | |

|Inappropriate language |Obtain peer attention |Loss of privilege |

|Physical contact |Obtain adult attention |Conference with student |

|Defiance |Obtain items/activities |Recess Detention |

|Disruption |Avoid Peer(s) |Parent Contact |

|Property misuse |Avoid Adult |Solution Center (      days) |

|Other       |Avoid task or activity |Boys & Girls Club (      days) |

|Major |Don’t know |Other       |

|Abusive language |Other       | |

|Fighting/Physical aggression | | |

|Overt Defiance | | |

|Harassment/tease/taunt | | |

|Disruption | | |

|Other       | | |

Others involved in incident: None Peers Staff Teacher Substitute

Unknown Other      

Other comments:     

I need to talk to the students’ teacher I need to talk to the administrator

Parent Signature: ______________________________ Date: ___________________

All minors are filed with classroom teacher. Three minors equal a major.

All majors require administrator consequence, parent contact, and a signature.

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