SAYDEL COMMUNITY SCHOOL DISTRICT PBIS OFFICE REFERRAL

Student: _________________ Referred By: Batten (Ickowitz Student Teacher) LOCATION: Bus Home Office Classroom Library Playground Common Area Locker Restroom Gymnasium Lunchroom School Grounds Hallway Grade: 10 Time: 1:19 Date: 9/27/12 Advisory Teacher:

Cornell Elementary Norwoodville Elementary Woodside Middle School Saydel High School

Off Grounds

ANTECEDENT: (What was happening before the student chose to demonstrate this behavior?) Class was just beginning was attemping to settle the class so that instruction may begin PROBLEM BEHAVIOR:
IF
MORE THAN ONE BEHAVIOR IS SELECTED, PLEASE NOTE

PRIMARY BEHAVIOR

AND

SECONDARY BEHAVIOR

IN

DESCRIPTION

OF

BEHAVIOR

BOX.

Abusive Language Incomplete School Work Possession of a Weapon

Destruction of Property Noncompliance Possession of Alcohol/Drugs

Disruption Overt Disrespect Tardy Theft

Harassment Physical Aggression Truancy

DESCRIPTION OF BEHAVIOR DEMONSTRATED BY STUDENT: _______ had previously barrowed another studetns (_________) laptop charger. Upon ________ request for returning said charger, _______ was repediatly disruptive to my several attempts to get class started. Letting something that could have been a courteous exchange of ________ property escalate into a larger issue. After asking politley for them to get it resolved so that we may begin class, ________ had found the charger from his backpack and tossed it at the feet of _______ rather than handing it over. Due to the apparent disruption to class and disrespect towards another studnet I asked _______ to please head down to the office. On his way out of the classroom, ______ was again acting disruptive by making his actions to pack up his items delibritly known and cursing the 'F' word on his way out. This hasnt been the only time where _______ has been disruptive in class but I have resolved previous incidents in class by reinfrocing the nature that class sould be less disruptive as asked for in the classroom guidelines.

CONSEQUENCE: Community Service Loss of Privilege Suspension POTENTIAL FUNCTION

OF

Detention No Action Taken Teaching Interaction

Expulsion Out of School Suspension

Home Contact Overcorrection Time Out

In School Suspension Restitution/Apology Verbal Reprimand

BEHAVIOR: Gain Peer Attention Avoid Peer Attention Dont Know Gain Object or Activity Avoid Task or Activity Other Gain Stimulation Avoid Work

Gain Adult Attention Avoid Adult Attention Communication CONTACT INFORMATION: Parent Name: Result of Contact:

Contact Number:

Date:

Time:

 Signature: Tim Batten Date: 9/27/12