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Name: _____________________________________ Date: _______________________

Teacher: _____________________ Time of incident: _______ Time return: ___________

Reflection Sheet

1. What were you doing? 2. What were you supposed to be doing?

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3. What are you going to do to fix or change 4. What will happen when you do fix the
that behavior? behavior?

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PARENT _________________________________
SIGNATURE: ___________________________________________________________
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RETURN TO
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SCHOOL
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Who was affected?
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