Appendix 1 Minor Behaviour Referral Form Student: Referred by: Room: Year: Date: Location of Incident: Time of Incident: After school Daily Fitness Toilets Before School Period 1 Art Room Music Room Transition Recess Period 2 Before School Excursion Undercover Lunch Eating Period 3 Classroom Library Area Lunch Play Period 4 French Room Oval Wet Area Period 5 Green Room Playground Other Phys Ed __________ MINOR- Teacher Managed Behaviour We Are Respectful We Are Responsible We Do Our Best We Are Safe Answering back Uncooperative Inattentive Minor physical Inappropriate Misuse of materials Lateness contact comments indirect Work avoidance Unprepared Out of boundaries at – swearing Technology misuse recess/lunch Minor dishonesty Misuse of property Not following Rough play instructions Unsafe behaviour Out of seat/area Name calling Cheating/integrity Teacher Actions Teacher Choices Bump 1 - Low key responses Classroom Playground Bump 2 Squaring off Isolation/time out in class Sit out – Bump 3 Student choice Isolation/time out in a partner Walk with teachers. – Bump 4 Teacher choice class. Other:_____________ – Bump 5- Power Struggle Notification to parents Parent conference For more detail refer to Completion of reflection explanation of CMS sheet.* ‘Minor Behaviour BUMPS’. Student has 3 slips in one week- Admin action required. Teachers to notify Admin. Comments:
Appendix 1 Minor Behaviour Referral Form Student: Referred by: Room: Year: Date: Location of Incident: Time of Incident: After school Art Room Before School Classroom French Room Green Room Phys Ed Daily Fitness Music Room Excursion Library Oval Playground Toilets Transition Undercover Area Wet Area Other __________ Before School Recess Lunch Eating Lunch Play Period 1 Period 2 Period 3 Period 4 Period 5 MINOR- Teacher Managed Behaviour We Are Respectful We Are Responsible We Do Our Best We Are Safe Answering back Inappropriate comments – indirect swearing Minor dishonesty Not following instructions Out of seat/area Name calling Cheating/integrity Uncooperative Misuse of materials Work avoidance Technology misuse Inattentive Lateness Unprepared Minor physical contact Out of boundaries at recess/lunch Misuse of property Rough play Unsafe behaviour Teacher Actions Teacher Choices Bump 1 - Low key responses Bump 2 – Squaring off Bump 3 – Student choice Bump 4 – Teacher choice Bump 5- Power Struggle For more detail refer to explanation of CMS ‘Minor Behaviour BUMPS’. Classroom Isolation/time out in class Isolation/time out in a partner class. Notification to parents Parent conference Completion of reflection sheet.* Playground Sit out Walk with teachers. Other:_____________ Student has 3 slips in one week- Admin action required. Teachers to notify Admin. Comments:
Student-Engagement-Guideline-10.docx