Student Name:

Referred by:

Date

Time sent

Location of incident

Grade

Homeroom Teacher

To be completed by sending staff member:

Behavior:

What was done in class to help student cool-down or redirect behavior?

Did this involve a policy infraction?

Harassment

Substance use

Weapon

Threat of harm

Technology

Other – specify:

To be completed by sending planning room supervisor:

Time arrived:

Plan established with student:

(include steps for making reparations to others who were affected by student’s actions plans for completing all work that was missed during this incident, and strategies the student will use in the future to avoid repeated incidents)

Parent notification:

Time dismissed from planning room:

To be completed by sending staff member (or homeroom teacher):

Time student returned to class:

Did student carry out plan for reparations and for completing missed work?

Did student show appropriate behavior upon return to class?

Other comments or concerns:

Please sign, attach student’s plan, keep a copy for your records, and return originals to planning room supervisor within 24 hours of student’s return to class.

Teacher Signature: __________________________________________Date:____________

Planning Room

Supervisor Signature: ________________________________________Date:____________

Principal Signature: __________________________________________Date:____________

If applicable,

Case Manager Signature: ______________________________________Date:____________

Planning Room supervisor will review with principal weekly and maintain student file.