Houston Independent School District
Sample of referral for PEIMS
events (Data reported to TEA) Houston Independent School District Discipline Referral Form
FSC checks referrals for all items in YELLOW.
Campus Name: HISD High School
Date of Referral: 2/22/16
Student ID: 1234567 Name: Donald Duckly
9 Grade:
Gender: M
Referred by: Susie Qzy
Location of Infraction: Classroom
2/22/16 9 am 2 713-343-1111 Incident Date: __________________ Incident Time: ____________ Room No.: ________________ Phone: ____________________________
Reason for Referral (Include reason on parent notification letter.)
Donald was caught in the Teacher's
Lounge. He has served two previous
detentions for this type of offense.
Disciplinary Action Taken by Teacher
Verbal reprimand and call to parents.
Date
2/22/16
* * * * * * * * * * * * * * * * * * * * * * * * * * For Administrative Use Only * * * * * * * * * * * * * * * * * * * * * * * * * *
13434 CHANCERY INCIDENT NUMBER:
Severity Level:
Level 1
x Level 2 Level 3
Level 4
Level 5
Local Reason (Offense) Code:
Select the Category of Incident for Bullying Allegations:
Disability
Race/Color/ National Origin
Religion
Local Action (Consequence) Code(s):
Sex
Sexual Orientation
Other:___________
PEIMS REASON (OFFENSE) CODE: __R_A_2__1____
PEIMS ACTION (CONSEQUENCE) CODE(S): _0_5_,_0__6____
Infraction Location
Codes
01(On Campus) 02 (Off Campus, within 300 ft) 03 (School Related/ Sponsored Activity Off Campus)
04 (Off Campus, not school related/ sponsored activity) 05 (On school property, or at school related/sponsored activity, of another school district)
PEIMS Actions (Consequences) Details: Begin Date End Date
Days
Days
Discrepancy
Assigned Completed
Reason
Campus Assigned
Campus Responsible
In-School Suspension (ISS) Out-of-School Suspension (OSS)
2/22/16 2/22/16 1 2/23/16 2/24/16 2
1
0
2
0
124 124 NA 124
Placement in DAEP Expulsion to JJAEP
Complete all fields for DAEP/JJAEP placements if applicable to offense.
OTHER ACTIONS: ARMS/Police Incident Number (if police notified) ___________________ Victim of Violent Crime Letter Y N
NOTE: Use one of the following PEIMS Action Codes when a Mandatory Action is not taken:
Check only
27 Special Ed. Student
Student's age and intent or lack of intent at the time the student engaged in the conduct
28 Reason for use of Mandatory Action Not Taken if applicable.
Potential effect of the misconduct on the school environment The facts of the case warrant consideration of self-defense as a mitigating
Student's attitude
factor in the assessment of any punishment
Seriousness of the offense Student's disciplinary history
The student has a disability that substantially impairs the student's capacity to appreciate the wrongfulness of the student's conduct
State law requirements for certain disciplinary consequences
Administrator's Comments:
Donald stated that he was in the Teacher's Lounge to get snacks. He said that he hates
cafeteria food. I reminded him that students can choose to purchase food from the
cafeteria or bring their lunch. Donald will return to class on Thursday, Feb. 25.
I have requested a conference with his parents after he returns.
IMPORTANT NOTE: The campus discipline coordinator/principal must complete, sign and date the referral form before the data is entered into Chancery. Signature stamps and copies of signatures are invalid. Do not send referrals home that include the names of other students that were involved in the incident.
Administrator's Signature Administrator must sign and date referral form in ink.
Date
Student's Signature
Date:
Parent's Signature
Date:
................
................
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