SEED MD Discipline Referral Form (2019-2020)
PLEASE COMPLETE AND SUBMIT TO: Interim Dean of Students (Mrs.Boyd), Dean of Students (Mr. Wilson), Dean of Students (Mr.Stokes) , AND the Director of Student Support (Mr.Carter-Bey)
Type of referral
Academic day referral
Student life referral
Date of Incident
Name of Person Referring (First and Last)
Name of Student (First and Last)
What grade is the student in?
Please list the specific room number and any other pertinent details about the location of incident
Common area (Hallways, SEED grounds, GYM)
BIP (Behavior Intervention Plan)
Is this Referral for Documentation Purposes only?
Select "Yes" for Level 1 & Level 2 infractions.
Please list any others involved in the incident as necessary
Please include any Scholar(s), Staff, or other person(s) involved and list their position
Which of the following strategies did you attempt before referring the scholar?
Asked scholar to explain the situation
Call to parent / guardian
Coaching / meet with student
Cool down / break time
Detention / in-class consequence
Differentiated instruction / task
Increased positive interactions with student
Non-verbal attention / visual cue
Positive reinforcement for appropriate behavior
Present both written and verbal directions
Proximity to student
I did not attempt any strategies.
Level I Infractions
Note: For staff documentation use only.
Classroom / dorm disruption
Failure to follow classroom / dorm rules or procedures
Dress code violation
Failure to be prepared
Internet / computer misuse
Public display of affection
Initiating or participating in any unacceptable minor physical actions
Level II Infractions
Serious or repeated Level I behavior
Class cutting / truancy
Defying the authority of school personnel
Fighting with minimal to no physical injury
Inappropriate language used towards another student or staff member
Theft Below $100
Threat to person or property
Unauthorized sale or distribution of items
Unauthorized use of portable communication devices
Unauthorized use of electronic devices
Level III Infractions
Serious or repeated Level II behavior
Fighting with serious injury
Inciting others to violence or disruption
Repeatedly disruptive conduct
Theft - more than $100
Threat to SEED MD employee
Tobacco - possession or use
Unauthorized possession, use, or distribution of over-the-counter medication
Level IV Infractions
Serious or repeated Level III behavior
Acts of gross misconduct at other schools
Assault - substantial bodily injury
Group fight - substantial bodily injury
Acts of violence
Physical attack of SEED employee
Possession, use, or distribution of controlled substances, dangerous substances, or drug paraphernalia
Sexual activity, sexual misconduct, or sexual harassment II
Vandalism / destruction of property - above $500
Please provide a brief description of specific behavior that warranted referral (Facts ONLY)
Send me a copy of my responses.
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