Student(s) _________________ Referring Staff _____________ Grade Level ____ Date ______ Time ___ Location Classroom Cafeteria loading zone Other __________ lot Playground area bus breezeway Library event/assembly/ field trip East Problem Behaviors (check the most intrusive) MINOR MAJOR School Inappropriate lang. Abusive lang./ inappropriate language class Physical contact Fighting theft non-compliance damage aggression code Disruption violation threat Dress Code insubordination/non-compliance violation tease/ taunt Property misuse Other __________ Tardy __________________________ Display of Affection Violation Possible Motivation Obtain peer attention Avoid tasks/activities Don’t know Obtain adult attention Avoid peer(s) Other ________________ Obtain items/ activities Avoid adult(s) Others Involved None Peers Teacher Substitute Unknown Other ___________________ Administrative Decision in office Saturday School In-school suspension Days ______ Loss of privilege Parent contact Individualized instruction suspension _____ Days Conference with student Other _______________ Comments:
Student(s) _________________ Referring Staff _____________ Grade Level ____ Date ______ Time ___ Location area breezeway East loading zone lot bus event/assembly/ field trip __________ Problem Behaviors (check the most intrusive) MINOR Inappropriate lang. contact non-compliance Dress Code violation misuse __________________________ MAJOR lang./ inappropriate language aggression insubordination/non-compliance tease/ taunt Display of Affection Violation class theft code violation School Property damage threat __________ Possible Motivation peer attention tasks/activities know adult attention peer(s) ________________ items/ activities adult(s) Others Involved ___________________ Administrative Decision in office Saturday School In-school suspension Days ______ of privilege contact Individualized instruction suspension Days _____ with student _______________ Comments: Playground Library Cafeteria Classroom Other Physical Disruption Tardy Other Abusive Fighting Other Obtain Obtain Obtain Avoid Avoid Avoid Don’t Other Loss Conference Parent Other None Peers Teacher Substitute Unknown
SWIS_ODR_Example.docx