Behavior Referral Form / Reporte de Comportamiento Teacher

Orange Grove Elementary School
3525 W. County 16 1/2
P.O. Box 3200, Somerton, AZ 85350
(928) 341-6200 Fax: 341-6290
Kim Seh, Principal
Behavior Referral Form / Reporte de Comportamiento
Name: ___________________________
Date: ____________ Time:
Teacher: ______________ Grade: K 1st 2nd 3rd 4th 5th
Time Frame:
During Official School Hours Before School After School Unknown
School Bus Stop
On School Bus
To/From School
Cyberspace
School-sponsored Event
Classroom
Hallway
Restroom
Cafeteria
Library
Gym
Other
Playground Bus Loading Area
Parking Lot
Other
Location/ Lugar: Off Campus:
On-campus- Inside:
On-campus- Outside:
Referred By: ___________________________
Minor Behavior Issues
State Reportable-Non-Mandatory
Other Violations of School Policy
____Defiance/Disrespect/Non-compliance /
Desafiante, Irrespetuoso, No Obedece
____Disruption / Interrupción
____Language, Inappropriate/ Lenguaje inapropiado
____Dress Code Violation / Vestimenta inapropiada
____Other
Aggression
____Verbal Provocation (Teasing) / Provocación
Verbal (Molestar/Burlarse)
____Minor Aggressive Act (Rough Play) / Acto
Agresivo Menor (Juego Rudo)
____Disorderly Conduct / Desorden
____Recklessness / Falta de Cuidado
Lying, Cheating, Forgery or Plagiarism
____Dishonesty / Deshonestidad
____Cheating / Copiar tarea o durante prueba
Theft
____Petty Theft / Robo menor
____Theft / Tomar propiedad ajena
Vandalism
____Property misuse / Uso inapropiado de propiedad
____Graffiti / Pintar, Rayar, Escribir
Other / Otro ___________
Teacher Action Taken
____Conference with student / Conferencia con estudiante
____Time Out / Retirado del grupo
____Student Apology / Disculpa del Estudiante
____Mediation / Mediación entre compañeros
____Loss of Privilege / Pérdida de Privilegios
____Loss of Recess / Pérdida de Recreo
____Lunch Detention / Pérdida del Recreo de Comida
____Parent Contact / Aviso a los Padres
____Referred to office / Referido a la oficina
Date of Last Parent Contact:
Major Behavior Issues
State Reportable-Mandatory
____Repeated Minor Infractions / Infracciones menores
repetidas o severas
Infraction/Infracción:
Harassment, Threat, Intimidation
____Harassment (Non-sexual)/Acoso no Sexual
____Bullying / Molestar Continuamente
____Threat or Intimidation / Amenazar o
Intimidar
____Hazing / Forzar a alguien a cometer actos
dificiles, humillantes, peligrosos
(Iniciación)
Aggression
____Endangerment / Poner en peligro a otros
____Fighting / Pleito
____Assault / Asalto Físico
School Threat
____Bomb Threat
____Fire Alarm Misuse
Sexual Offenses
____Indecent Exposure / Exponerse Indecentemente
____Sexual Harassment / Acoso Sexual
Theft
____Burglary / Entrar y robar
____Extortion
Weapons and Dangerous Items
____Firearms / Armas de Fuego
____Other Weapons / Otras Armas
____Dangerous Items / Artículos peligrosos
Other / Otro ___________
Administrative Decision
____Parent Contact / Llamada a los padres de familia
____Parent Conference / Junta con padres de familia
____Restitution / Restitución
____Verbal and/or Written Apology / Disculpa Verbal Escrita
____Behavior Contract or Plan / Plan o Contrato para
Mejorar la Conducta
____Threat Assessment / Evaluación de Riesgo
____In-school suspension (No. of Days: Dates:
)
____Out of school suspension (No. of Days: Dates:
)
____Work detail / Asignación de Trabajo
____Other ________________________
Comments:________________________________________________________________________________________
**Please sign and return this form / Favor de firmar y regresar esta forma
Parent Signature/Firma del Padre _______________________________________________
OGS Behavior Expectations / Expectativas de Conducta
Orange Grove School RROCKS: Respectful, Responsible, Organized, Caring, Knowledgeable, Safe
Los Tigres de Orange Grove “RROCK”son Respetuosos, Responsables, Organizados, Cuidadosos, Sabiduría, Seguros