Root Discipline Referral
First Name *
Your answer
Last Name *
Your answer
TEACHER: *
Your answer
INFRACTION DATE: *
MM
/
DD
/
YYYY
INFRACTION TIME *
Your answer
REFERRAL DATE: *
MM
/
DD
/
YYYY
OFFENSES
OFFENSES *
Check appropriate offense code
Required
PRIOR TEACHER ACTION *
Required
TEACHER COMMENTS *
Your answer
CONSEQUENCES
This section to be filled out by administrator.
Consequences
SUSPENSION
During OSS, student is prohibited from participating in and attendance at all school activities, and is not permitted on school grounds for any reason, including bringing or picking up other students, without prior authorization from the Principal.
SUSPENSION DETAILS
Your answer
ADMINISTRATOR
Your answer
ADMINISTRATION COMMENTS
Your answer
Today Date: *
MM
/
DD
/
YYYY
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