Cell Phone and Electronic Device Violation Form 
Please complete this form when a student is turning in a cell phone or electronic device to the office. 

  • Violation 1 Staff receives the device and places it in a safe location in the classroom for return to the student after the class period. Staff records the violation in a Google Form.


  • Violation 2 Staff receives the device and takes it to the office where the student can pick it up after school.  The teacher records the violation in a Google Form. The teacher contacts the family with a reminder of our policy.


  • Violation 3 Staff receives the device and takes it to the office where a family member must pick it up. The teacher records the violation in a Google Form. The administration contacts the family. The family receives a copy of the policy and signs the document.


  • Violation 4 The student must drop the device off at the office in the morning before 8:14 AM and pick it up at the end of school for the remainder of the quarter or semester, as deemed appropriate by the administration.
Sign in to Google to save your progress. Learn more
Date *
MM
/
DD
/
YYYY
Student's First Name *
Student's Last Name *
Teacher's Name *
Class Period *
Who in the office did you give the device to? *
Type of Device *
Comments
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of AUSD.

Does this form look suspicious? Report

Google Forms