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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