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STUDENT

GRADE
REFERRING STAFF

BEHAVIOR TICKET

HOMEROOM TEACHER
DATE TIME

LOCATION:
Classroom Playground Commons Hallway Bathroom Gym Media Center
Bus/Parking Lot On Bus Special Event/Assembly/Field Trip Other_________________

MINOR: (Homeroom Teacher)
MAJOR: (Principals Office)
DISRESPECT
Direct, Inappropriate Language/Gestures
Cheating
Fighting/Physical Aggression
Loud Voice/Yelling
Harassment/Bullying/Cyber Bullying
Name Calling
Over Defiance
Disrespectful
Property Destruction/Misuse/Vandalism
DEFIANCE
Theft
Breaking Cafeteria Rules
Violation of Internet Policy
Breaking Playground Rules
Threat in conversation, Writing, or Pictures of
Uncooperative
Weapons
DISRUPTION
Multiple Minor Violations
Inappropriate Bathroom Behavior
Running
Disrupting Classroom

INAPPROPRIATE LANGUAGE
Indirect, Inappropriate Language/Gestures

TECHNOLOGY VIOLATION
Cell Phones
Other Electronic Devices

POSSIBLE MOTIVATION:
Obtain Peer Attention Obtain Adult Attention Obtain Items/Activities
Avoid Tasks/Activities Avoid Peer(s) Avoid Adult(s) Escape Control/Power
Dont Know Other:____________________________

OTHERS INVOLVED:
None Peers Teacher Staff Substitute Other_______________

CONSEQUENCE:
Time in Office Loss of Privilege Conference with Student Noon Detention
Parent Contact In-School Suspension Out-of-School Suspension

Referral:_______________________________ Other:____________________________________

COMMENTS: