CLASSROOM INCIDENT REPORT

____________________________________(Student’s name) has been instructed to report to the office of the Senior Teacher, Deputy Principal/Principal for:

 Repeated failure to comply.  Speaking disrespectfully.  Refusing to do class work.  Using profanity.  Being continually off task.  Engaging in disruptive behavior.  Harassing classmates.  Endangering the safety of others.  Coming to class unprepared.  Arguing with the teacher or talking back.  Leaving the classroom without permission.  Refusing to leave the classroom upon request.  Possession of a weapon.  Wearing inappropriate clothing.  Wearing the school uniform inappropriately.  Physical aggression or fighting.  Destroying school/student/teacher property.  Using threats. Other: _________________________________________________

Warnings have been given… Yes No

Action taken by teacher includes… ____________________________________

_________________________________________________________________ _____ The student cooperated and complied immediately. _____ The student did not cooperate and refused to proceed to the office.

46

Teacher: _______________________ Date:______________________ Time: _____________ Period: ______