Building a Comprehensive School Discipline Referral Form

This is a sample school discipline referral form

Discipline referral form
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A school discipline referral form is utilized in most school districts. Each district tailors the referral form to meet their particular needs. There are many important reasons that school districts require their teachers and administrators to utilize these forms. These include:

  • Creating a paper trail to protect everyone involved.
  • Gives the principal a starting point and foundation for gathering information relevant to the behavior infraction.
  • Can help establish and document a pattern of student behavior.
  • Guides the discipline process ensuring that every student sent the office on a discipline referral is being met with the same process. 
  • Forces the teacher to evaluate what prior strategies they have implemented on their own to attempt to correct the behavior.

Schools that do not use a school discipline referral form to document student behavior issues will likely have several obstacles should legal action be taken by a constituent of the district. Filling out and adhering to a school discipline referral form does take time. However, it is worth it as serves to protect everyone involved in the process.

Categories Defined 

  • Others Involved - None, Peers, Teacher, Staff, Sub, Other
  • Potential Witnesses - List all people who are not directly involved, but may have seen the incident.
  • Nature of Incident - Excessive Talking, Unprepared for Class, Excessive Tardies, Inappropriate Language, Violation of Dress Code, Disrespect, Violation of School Bus Rules, Disorderly Conduct, Defacing Property, Truancy, Lying/Cheating, Uncooperative, Horseplay, Misuse of Electronic Device, Harassment, Bullying, Fighting/Assault, Vandalism, Violation of State & Federal Laws, Violation of School Policy, Other
  • Describe Incident - List a detailed description of the incident containing all of the known facts.
  • Possible Motivation - Avoid Activity, Avoid Adult, Avoid Peers, Avoid Task, Obtain Peer Attention, Obtain Adult Attention, Obtain Activities, Obtain Items, Other, Don't Know
  • Previous Classroom Discipline History of Student - Explain other behavior issues (related and unrelated) you have had with the student in the class.
  • Previously Used Teacher Intervention Strategies - Counseling Referral, Parent Conference, Conference with Student, Seat Change, Detention, Loss of Privilege, Social Skills Instruction, Extra Assignment
  • Student's Statement - Provides the student with an opportunity to explain themselves and become a part of the process to find a solution.
  • Consequences Assigned by Administrator - Class Removal, Campus Beautification, Counseling Referral, Alternative Placement, Loss of Privilege, Detention, Conference with Student, Mentoring, Conference with Parent, Out-of-School Suspension, In School Placement, Expulsion
  • Follow-Up Plan - Provides an opportunity to check up on the student, provide the resources, and a plan to support them in correcting the behavior.

Sample School Discipline Referral Form

Student Name: _____________________________________ Grade:_______________________

Referring Teacher: _________________________________________________

Date: ___/___/___  Time:____________ Location: ______________________________________

Others Involved: ________________________________________________________________

Potential Witnesses: _____________________________________________________________

Nature of Incident: ______________________________________________________________

Describe Incident:   ______________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Possible Motivation: ______________________________________________________________

_______________________________________________________________________________

Previous Classroom Discipline History of Student

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Previously Used Teacher Intervention Strategies (If applicable)

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Teacher Signature: ______________________________________________________________

Administrator's Report 

Student’s Statement

What rule did you violate? ___________________________________________________________

Why did you violate the rule? _________________________________________________________

Did you get what you wanted? ________________________________________________________

What is another alternative to get what you want? _________________________________________

_________________________________________________________________________________

Consequences Assigned by Administrator 

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Parent Notification Method 

______ Phone Call ______ In Office ______ Email ______ Letter ______ Other _____________

Referral to Other Services (If Necessary)

______ Discipline Review Team _______ Counseling _______ Local Authorities ______Other

Follow up Plan 

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Student Signature: _________________________________________ Date: ____/_____/_____

Administrator Signature: _____________________________________ Date: ____/_____/_____

Parent Signature: __________________________________________ Date: ____/_____/_____