STUDENT NAME - Florida Department of Education



|NAME |GENDER |GRADE |REPORTED BY |DATE |TIME |

|Reason for Referral: ___________________________________________________________________________________________ |

|___________________________________________________________________________________________________________________________________________________________________|

|_____________________________________________________ |

|INCIDENT LOCATION |NON-SESIR INCIDENTS |

|(1) School Grounds: |__Office |Non-SESIR fighting |Tardy |

|__Bathroom/Restroom |__Parking Lot |Abusive/Inappropriate Language |Skip Class/Truancy |

|__Bus ramp |__Playground |Defiance/Disrespect/ Insubordination/ |Dress Code Violation |

|__Cafeteria |__Other: ______________ |Non-compliance |Theft under $300 |

|__Classroom | |Lying/Cheating |Use/Possession of Combustibles |

|__Commons/Common Area |(2) School-Sponsored Activity/Off |Tease/Taunt (one event) |Property Damage under $1000 |

|__Gymnasium/P.E. |Campus |Disruption - Minor |Other: ______________ |

|__Hallway/Breezeway |(3) School- Sponsored Transportation:| | |

|__Library/Media Center |Bus #_____/Bus Stop | | |

|OFFENDER(S) |If multiple students, list: |DISTRICT ACTION CODE |

|(S) Student(s) | |Time in Office |Saturday School |

|(B) Both student(s) and non- student(s) |___________________ |Loss of Privileges |Bus Suspension |

|(N) Non-student(s) only |___________________ |Conference with Student |In-school Suspension |

|(U) Unknown |___________________ |Parent Contact |Out-of-School Suspension |

|(Z) N/A-Unsubstantiated |___________________ |Detention |Other:_____________ |

| |___________________ |Individualized Instruction | |

| ↓SESIR INCIDENTS↓ [] |

| |RELATED ELEMENTS |ACTION CODES FOR SESIR INCIDENTS |

|Expected to include consultation with Law Enforcement | | |

|(ALC) Alcohol |(KID) Kidnapping |(Check all that apply) |(I) In-School Suspension |

|(ARS) Arson |(PHA) Physical Attack |Alcohol Related |(O) Out-of-School |

|(BAT) Battery |(ROB) Robbery |Bullying Related |Suspension |

|(BRK) Breaking & Entering/Burglary |(STL) Larceny/Theft (over $300) |Basis: □race □sex □disability |(H) Suspension Extended, |

|(DOC) Disruption on Campus-Major |(SXA) Sexual Assault |□sex. orientation □religion |Pending Hearing |

|(DRD) Drug Sale/ Distribution |(SXB) Sexual Battery |Drug Related (Description) |(OSS only) |

|(Marijuana(M) |(SXO) Sexual Offenses (Other) |Gang Related |(E) Expulsion Without |

|(Other(O) |(TRE) Threat/Intimidation |Hate Crime Related |Services |

|(Non-Drug(N) |Basis: □race □sex □disability |Hazing Related |(Zero-Tolerance(Y) |

|(DRU) Drug Use/ Possession |□sex. orientation □religion |Injury Related (check one): |(F) Expulsion With |

|(Marijuana(M) |(TRS) Trespassing |__(A) More Serious |Services |

|(Other(O) |(VAN) Vandalism (over $1000) |__(B) Less Serious |(Zero-Tolerance(Y) |

|(Non-Drug(N) |(WPO) Weapons Possession |Weapon Related (check one): |(P) Alternative Placement |

|(HAZ) Hazing |(OMC) Other Major (unlawful |__(1) One non-firearm |(S) SESIR Defined |

|(HOM) Homicide |activities) |__(2) Two or more non |(U) Change In Placement |

| | |firearms |(students w/ disabilities) |

| | |__(3) At least one firearm |(M)Mechanical Restraint |

| | |__(4) Two or more firearms |(R) Physical Restraint |

| | | |(L) Seclusion |

| | | |Non-student/Unknown: |

| | | |Discipline N/A |

| | | |No Discipline- |

| | | |Unsubstantiated |

| | | |_________________________ |

| | | | |

| | | |If suspended (school or bus), suspension|

| | | |is for ______ days: |

| | | | |

| | | |Start date:________________ |

| | | | |

| | | |End date:_________________ |

|May not require consultation with Law Enforcement |Weapon Description: | |

| |(F) Firearm, Other | |

| |(H) Handgun | |

| |(K) Knife | |

| |(O) Other Weapon | |

| |(R) Rifle/Shotgun | |

| |(U) Unknown | |

| |(M) Multi. Type Firearms | |

| | | |

| |Weapon, Discharged: | |

| |(for F, H, R or M above) | |

| |(N) No | |

| |(Y) Yes | |

|(BUL) Bullying |(UHR) Unsubstantiated | | |

|Basis: □race □sex □disability |Harassment* | | |

|□sex. orientation □religion |Basis: □race □sex □disability | | |

|(UBL) Unsubstantiated |□sex. orientation □religion | | |

|Bullying* |(FIT) Fighting | | |

|Basis: □race □sex □disability |(SXH) Sexual Harassment | | |

|□sex. orientation □religion |Basis: □race (sex □disability | | |

|(HAR) Harassment |□sex. orientation □religion | | |

|Basis: □race □sex □disability |(TBC) Tobacco | | |

|□sex. orientation □religion | | | |

|*Use these codes for incidents reported as BUL or HAR, that once investigated, | | |

|do not meet the definition of BUL or HAR. | | |

|VICTIM(S) |

|For SESIR incidents highlighted above (TRE, BUL, HAR, UBL, UHR, SXH or any incident that is Bullying Related), complete the following: |

|Victim Name(s) or Student Number Identifier(s) Basis for Bullying or Harassment (check all that apply) |

|_______________________________________ □Race □Sex □Disability □Religion □Sexual Orientation _______________________________________ |

|□Race □Sex □Disability □Religion □Sexual Orientation |

|_______________________________________ □Race □Sex □Disability □Religion □Sexual Orientation |

|For SESIR Homicide (HOM) incidents - Victim(s) of Homicide: □ Staff (E) □ Faculty (F) □ Other (O) □ Student (S) |

|SCHOOL-RELATED ARREST(S) |

|For any student arrested for an activity on school grounds, during off-campus school activities, or on school transportation, or for arrests due to a referral by |

|any school official, complete the following: |

|Name(s) of Arrested Person(s) |

|_______________________________________ _______________________________________ |

|_______________________________________ _______________________________________ |

Law Enforcement Involvement: Yes_____ (case number, report, affidavit, arrest) Consultation______ No______

Revised January 2019

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