Bridgeport Catholic Academy

Mr. Wilhelmi

Student: ________________________________________________ Date: ______/______/ 2017

YOU ARE NOT IN TROUBLE I just need you to tell me how I can help you be a positive young person in my class. This is your chance to
work with me in helping you stay on task.

Behavior (Teacher fills-in) Interventions/ Restorative Responses

(Mark all that apply)
Insubordination X_____ Mr. Wilhelmi can help me be a positive member of class/school by:
Disruptive behavior _____________________________________________________________________________________
Out of seat
_____________________________________________________________________________________
Inappropriate
conversations _____________________________________________________________________________________
Clowning around _____________________________________________________________________________________
Interfering with
_____________________________________________________________________________________
teacher activities
Insulting remarks _____________________________________________________________________________________
Rudeness _____________________________________________________________________________________
Defiance/ Hostility
_____________________________________________________________________________________
Head on desk/ sleeping/
laying in seat
Unprepared For Class The reason I am disrupting class is:
Textbook I have an issue that I do not want to talk about
Notebook I am having trouble with another student in (circle one) class/ building
Writing utensil I am having trouble with an adult
Assignment or I have an issue that occurred outside class/ school
avoiding classwork
________________________ OR:
________________________ I do not understand the assignment(s)
________________________ The work is too easy and I get bored (provide heightened assignments and/or student coaching)
________________________ I have an interesting question for you to discuss in class (Parking Lot sheets)
________________________ Other comments: ______________________________________________________________________
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Teacher Comments/Narrative: _________________________________________________________________________________________

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