Student Timeout Pass Form
Use this form to issue and track student timeout passes efficiently and accurately.
Student Name
*
First Name
Last Name
Grade
*
Please Select
6
7
8
9
10
11
12
Other
Teacher/Staff Issuing Pass
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time Out
*
Hour Minutes
AM
PM
AM/PM Option
Destination
*
Please Select
Counselor's Office
Main Office
Library
Restroom
Other
Reason for Timeout
*
Please Select
Personal Break
Behavioral Redirect
Requested by Student
Requested by Teacher
Other
Time Returned
Hour Minutes
AM
PM
AM/PM Option
Staff Initials on Return
Additional Notes (optional)
Submit Pass
Should be Empty: