22-23 REFERRAL FORM  
Kindly use this form to report "in-person" violations of our code of conduct.  The information sought will assist our administration and key personnel in addressing your concerns as thoroughly and expeditiously as possible.  Upon submission, a copy of this form may be transmitted to all administrators, our library team, and additional supports.  It will also be presented to the scholar and parent/guardian should they wish to review it.  

Please remember to clearly relay classroom expectations, address inappropriate behavior with the class and the individual student separately, and document corrective measures (include talking to the class, talking to the individual, and reaching out to parents).  Please note the removal of a scholar will only take place if they engage in activities clearly defined or in line with those listed as a major issue of concern below.  All other violations will be addressed by an administrator as the referral is received.    
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Email *
YOUR LAST NAME, FIRST NAME *
Your department
DATE OF VIOLATION *
MM
/
DD
/
YYYY
PERIOD OF OCCURRENCE *
STUDENT LAST NAME, FIRST NAME (Write unknown if unknown.)   *
STUDENT ID # IF KNOWN (Write unknown if you do not have way of accessing ID#) *
IF KNOWN, STUDENT GRADE
Clear selection
DID INCIDENT INCLUDE ANOTHER STUDENT? *
IF ISSUE INCLUDED ANOTHER PERSON, PLEASE ADD NAME, GRADE, ID (IF KNOWN) OF ALL OTHERS INVOLVED
LOCATION OF INCIDENT (If incident occurred in hallway, list closest room number.) *
REASON *
LOW LEVEL ISSUE OF CONCERN (NO REMOVAL)-Classroom Management (Referral Submission for documentary purpose) *
Required
MID LEVEL ISSUE OF CONCERN-Administrative (Referral Submission)-ADMINISTRATIVE SUPPORT Requested-Removal may be required *
Required
MAJOR ISSUE OF CONCERN-Requires Removal of Scholar (Submission of Referral) *
Required
BRIEFLY DESCRIBE OCCURRENCE. (This info may be shared with the student/family and will be logged in Power School.)  
If you sent the student student to pass room or had the scholar removed, we may need you to meet with an administrator, the scholar, and or potentially a parent/guardian.  Please advise as to what period you are available to meet tomorrow. *
Required
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