Disengaged student log
Tier one attendance records will be maintained by the teacher. If you are working with a family on a differentiated plan, please keep that at tier one and monitor engagement. If you have a student who is disengaged despite tier 1 interventions, please use this form to refer the student for tier II or III intervention. If you have already submitted this form and you are working with the counselors and administration on a tier II/III plan, you do not need to fill in this form again. We meet weekly to discuss the disengaged students, please email if there are any updates.

Thank you for your continued persistence and dedication.
Homeroom Teacher Name *
Grade *
Instructional Week *
Name of Student *
How teacher has already attempted to contact this week. (check all that apply) *
Date of last phone contact by teacher. *If filling this form out please ensure you have made phone contact with the parent* and allowed enough time for parent to return your call. *
Any additional information on the child that would be helpful to know prior to Admin/Counselor intervention? *
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