2019-2020 Detention & Office Referral Form
Please use this form to document if classroom managed discipline was utilized, or if the behavior requires administrator action in the form of a office referral.
If submitting a detention, please complete the green detention form on paper, provide a paper copy to the student, contact parents/guardians, then complete and submit the following form below online.
Please e-mail or see Scott Stasa if you have any questions
1. Staff Member's Name (Last Name, First Name)
2. Student's Name (Last Name, First Name)
3. Is the student's behavior considered classroom managed or office managed?
Classroom managed (detention assigned)
Office managed (administration to assign consequence)
4. If classroom managed, select date of detention assigned (Tues/Thurs 3:15-4:00 Room 109).
5. Student's Grade Level
6. Does the student receive special education services?
7. Student's Ethnicity.
American Indian/Alaskan Native
8. Date of Incident Occurrence
9. Approximate Time of Incident Occurrence
10. Location of Incident Occurrence.
11. Written Description of Incident
12. Student Behavior Category. Please select all that apply.
Harassment / Intimidation
Serious threat to others/self
Property misuse / Vandalism
Disorderly Conduct / Disruption
13. Interventions Used Prior to Submitting Form. Select all that apply.
Conference with student
Review expectations/school policies
Detention (for original offense)
Communication must be made to the student's parents/guardians by the staff member issuing the detention. Please stop in to the main office if you need assistance locating a student's contact information.
14. Communication to parent/guardian:
Did not communicate (Office Referrals only)
Classroom app (ClassTag, ClassDojo, etc.)
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This form was created inside of Willoughby-Eastlake City School District.