Student Name

First Name Last Name

Grade

Date of incident

Time of Incident

Staff Reporting Incident

Email of staff reporting Incident

Infraction

Bullying Improper Use of Personal Devices Inappropriate Behavior(Class 2) False Fire Alarm(Class 2) Hitting(Class 2) Instigating(Class 2) Skipping Class(Class 2) Threat/Intimidation(Class 2) Tobacco(Class 2) vandalism(Class 2) Instigating(Class 2) Alcohol(Class 3) AWOL(Class 3) Disorderly Conduct(Class 3) Drugs(Class 3) Fighting(Class 3) Gang Activity(Class 3) Other Criminal Offenses(non-violent)(3) Sexual Harassment (Class 3) Theft/Larceny (Class 3) Arson(Class 4) Battery(Class 4) Breaking & Entering(Class 4) Explosives(Class 4) Motor Vehicle Theft(Class 4) Robbery(Class 4) Sexual Offenses(Class 4 ) Firearms Possession(Class 4) Weapons(Knives-fixed folded or edged)(Class 4)

Location of Incident

Detail for referral and infraction

Principal fills out the remainder of the form after it has been submitted and principal talks with the student. Please click on the submit button above

Actions Taken(principal fills out)

Details of Action Taken

Conference held with student on:

Parents Contacted by whom and when

Comments by administration or designee

Email(teacher)

example@example.com

Email(Teacher)

Signature

Clear

Check when completed

Infraction has been dealt with and completed

Check when completed

Incident has been logged into DDN

OLCSD