RecoveryReflectionForm

1. I was not being Respectful/ Responsible/ Safe (Circle one) because I was (talking,
blurting out, out of my seat, etc.. Please be specific.)

________________________________________________________________________
________________________________________________________________________

2. The reason(s) I was not meeting the expectations was (circle your reason(s)):

I was trying to get attention from the teacher.

I was trying to get attention from my classmates.
I was trying to avoid doing my work.
Other_________________________________

3. Fix it Plan: In order to be respectful, responsible and safe, I plan to:

________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

4. I would like extra help from an adult to solve this. Yes/ No (Circle one)

Teacher Use:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

Revised 9.15.14