Referral Form Discipline Referral Form Discipline Referral Form Date Time 12:00 AM12:05 AM12:10 AM12:15 AM12:20 AM12:25 AM12:30 AM12:35 AM12:40 AM12:45 AM12:50 AM12:55 AM1:00 AM1:05 AM1:10 AM1:15 AM1:20 AM1:25 AM1:30 AM1:35 AM1:40 AM1:45 AM1:50 AM1:55 AM2:00 AM2:05 AM2:10 AM2:15 AM2:20 AM2:25 AM2:30 AM2:35 AM2:40 AM2:45 AM2:50 AM2:55 AM3:00 AM3:05 AM3:10 AM3:15 AM3:20 AM3:25 AM3:30 AM3:35 AM3:40 AM3:45 AM3:50 AM3:55 AM4:00 AM4:05 AM4:10 AM4:15 AM4:20 AM4:25 AM4:30 AM4:35 AM4:40 AM4:45 AM4:50 AM4:55 AM5:00 AM5:05 AM5:10 AM5:15 AM5:20 AM5:25 AM5:30 AM5:35 AM5:40 AM5:45 AM5:50 AM5:55 AM6:00 AM6:05 AM6:10 AM6:15 AM6:20 AM6:25 AM6:30 AM6:35 AM6:40 AM6:45 AM6:50 AM6:55 AM7:00 AM7:05 AM7:10 AM7:15 AM7:20 AM7:25 AM7:30 AM7:35 AM7:40 AM7:45 AM7:50 AM7:55 AM8:00 AM8:05 AM8:10 AM8:15 AM8:20 AM8:25 AM8:30 AM8:35 AM8:40 AM8:45 AM8:50 AM8:55 AM9:00 AM9:05 AM9:10 AM9:15 AM9:20 AM9:25 AM9:30 AM9:35 AM9:40 AM9:45 AM9:50 AM9:55 AM10:00 AM10:05 AM10:10 AM10:15 AM10:20 AM10:25 AM10:30 AM10:35 AM10:40 AM10:45 AM10:50 AM10:55 AM11:00 AM11:05 AM11:10 AM11:15 AM11:20 AM11:25 AM11:30 AM11:35 AM11:40 AM11:45 AM11:50 AM11:55 AM12:00 PM12:05 PM12:10 PM12:15 PM12:20 PM12:25 PM12:30 PM12:35 PM12:40 PM12:45 PM12:50 PM12:55 PM1:00 PM1:05 PM1:10 PM1:15 PM1:20 PM1:25 PM1:30 PM1:35 PM1:40 PM1:45 PM1:50 PM1:55 PM2:00 PM2:05 PM2:10 PM2:15 PM2:20 PM2:25 PM2:30 PM2:35 PM2:40 PM2:45 PM2:50 PM2:55 PM3:00 PM3:05 PM3:10 PM3:15 PM3:20 PM3:25 PM3:30 PM3:35 PM3:40 PM3:45 PM3:50 PM3:55 PM4:00 PM4:05 PM4:10 PM4:15 PM4:20 PM4:25 PM4:30 PM4:35 PM4:40 PM4:45 PM4:50 PM4:55 PM5:00 PM5:05 PM5:10 PM5:15 PM5:20 PM5:25 PM5:30 PM5:35 PM5:40 PM5:45 PM5:50 PM5:55 PM6:00 PM6:05 PM6:10 PM6:15 PM6:20 PM6:25 PM6:30 PM6:35 PM6:40 PM6:45 PM6:50 PM6:55 PM7:00 PM7:05 PM7:10 PM7:15 PM7:20 PM7:25 PM7:30 PM7:35 PM7:40 PM7:45 PM7:50 PM7:55 PM8:00 PM8:05 PM8:10 PM8:15 PM8:20 PM8:25 PM8:30 PM8:35 PM8:40 PM8:45 PM8:50 PM8:55 PM9:00 PM9:05 PM9:10 PM9:15 PM9:20 PM9:25 PM9:30 PM9:35 PM9:40 PM9:45 PM9:50 PM9:55 PM10:00 PM10:05 PM10:10 PM10:15 PM10:20 PM10:25 PM10:30 PM10:35 PM10:40 PM10:45 PM10:50 PM10:55 PM11:00 PM11:05 PM11:10 PM11:15 PM11:20 PM11:25 PM11:30 PM Grade Level 0 1 2 3 4 5 6 7 8 Refer to Discipline Team No Yes Homeroom Teacher Allena Krank Cardella Williamson Chris Gray Colette Schwenk Don Holley Edie McBride Jaci Tanner Jenna Gregory Jennifer Montoya Jenny Holley Jim McBride Judy McLendon Kristen Williamson Laura McDaniel Select Role * Office Staff Support Staff Teacher Referred Student Select Staff Member Primary Infraction Category aggression alcohol Arson and Threats to the School Attendance bus Defiance drugs Failure to Follow Procedures Lying Other Violations of School Policies Sexual Harrassment Technology Theft Tobacco Trespassing vandalism Weapons and Dangerous Items 2nd Infraction Category aggression alcohol Arson and Threats to the School Attendance bus Defiance drugs Failure to Follow Procedures Lying Other Violations of School Policies Sexual Harrassment Technology Theft Tobacco Trespassing vandalism Weapons and Dangerous Items 3rd Infraction Category aggression alcohol Arson and Threats to the School Attendance bus Defiance drugs Failure to Follow Procedures Lying Other Violations of School Policies Sexual Harrassment Technology Theft Tobacco Trespassing vandalism Weapons and Dangerous Items 4th Infraction Category aggression alcohol Arson and Threats to the School Attendance bus Defiance drugs Failure to Follow Procedures Lying Other Violations of School Policies Sexual Harrassment Technology Theft Tobacco Trespassing vandalism Weapons and Dangerous Items Primary Infraction 2nd Infraction 3rd Infraction 4th Infraction Enter description and names of witnesses Primary Action Category Detention Due Process Interventions Other 2nd Action Category Detention Due Process Interventions Other 3rd Action Category Detention Due Process Interventions Other 4th Action Category Detention Due Process Interventions Other Primary Action Taken 2nd Action Taken 3rd Action Taken 4th Action Taken Duration Action Start Date Action End Date Demerits If you are human, leave this field blank. Submit
