2019-20 Tigerton Schools Behavior Referral Form
Please use this form to document all behavior concerns. Designate as MINOR if the behavior will be addressed by you in the classroom, MAJOR if you are referring the student to the office.
Email address *
Severity of Incident *
(Minor - teacher managed vs Major - office managed)
Student Last Name *
Your answer
Student First Name *
Your answer
Grade *
Gender *
Time of Incident *
Date of Incident *
Location of Incident *
Is Bullying or Harassment involved in this incident? *
3 elements must be present in order to be considered bullying: the act must be aggressive with intent to harm, there must be an imbalance of power between the offender and recipient, and it must be persistent or repetitive.
If YES, what type of bullying?
If YES, what type of harassment?
Inappropriate Behaviors: Minor offenses only
Choose from the list the most fitting problem behavior. Please phone home for minor defiance, disrespect, noncompliance
Inappropriate Behaviors: Major offenses only
These are behaviors that need to be addressed by the Administration. Check all that apply.
Others Involved in the Incident
Check all that apply
Possible Motivation *
Action(s) taken by Staff *
Check all that apply
Parent contact information
Indicate date, time, name of person contacted or message
Your answer
Comments regarding the incident
Your answer
Do you want a copy of this Minor Referral mailed home?
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