Building a Comprehensive School Discipline Referral Form

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. 



    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.


    • Others Involved - None, Peers, Teacher, Staff, Sub, Other


    • Potential Witnesses - List all people who are not directly involved, but may have seen to 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 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 them resources, and a plan to support them in correcting the behavior.



        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: ______________________________________________________________


        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? _________________________________________







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

        REFERRAL TO OTHER SERVICES (If necessary)

        ______ Discipline Review Team _______ Counseling _______ Local Authorities ______Other





        Student Signature: _________________________________________ Date: ____/_____/_____

        Administrator Signature: _____________________________________ Date: ____/_____/_____

        Parent Signature: __________________________________________ Date: ____/_____/_____

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        Your Citation
        Meador, Derrick. "Building a Comprehensive School Discipline Referral Form." ThoughtCo, Sep. 6, 2015, Meador, Derrick. (2015, September 6). Building a Comprehensive School Discipline Referral Form. Retrieved from Meador, Derrick. "Building a Comprehensive School Discipline Referral Form." ThoughtCo. (accessed January 19, 2018).