AJHS Student Referral Form 2
Electronic Referral Form
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AJHS Student Referral Record: Instructor
Student Last Name
*
Student First Name
*
Grade:
*
7
8
Referred by: (instructor name)
*
Period
*
B4 School
1
2
Break
3
4
Lunch
5
6
After School
Contacted parent/gaurdian prior to referral
*
Made contact
Left a message
did not make contact or leave a message
Will make contact after school
Made contact earlier in the quarter/year
Date of parent/gaurdian contact
*
Briefly Describe Incident
*
Interventions implemented by instructor prior to this referral
*
2. Changed student's seat(s)
3. Conference with student
4. Detention(s) with teacher during break or lunch
5. Administered consequences in classroom based on class rules/norms for behavior
6. Referral to counselor
7. Conferenced with other instructors of this student.
8. Multiple warnings/repeat offenses
Other
Explain Other
Consequences recommended by Instructor
*
Student suspended from class for a day
Detention with teacher
Detention after school
Develop behavior contract with student , instructor, & parent
Saturday School Detention
Other
Explain Other Recommendation:
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All information below for office use only
Student Statement:
Adminstrative Actions
Student conference
Teacher must contact parents regarding this issue
Student behavior contract will be developed with student by instructor & parent
Detention (after school) assigned
Saturday School Detention Assigned
Suspended from class for one day
Other
Explain other
Student was interviewd
Yes
No
Parents were notified by administration?
Yes
No
By phone
In person
Via Email
Date of Parental Notification
Should be Empty:
