Revised July 2006
SCHOOL DISTRICT #22 (VERNON) BEHAVIOUR REPORT
Date of Incident:
Cims _____Y _____N
Name:
Classroom Teacher: Location: Bus Bus Zone Change Room Time (24 H):
Reported by:
Classroom Courts Field Trip
Grounds Gym Hallway
Off Grounds Parking Lot Play Equipment
Washrooms
Details:
Staff Signature: Admin Action: Physical Agression (PAG) Action Plan (ACP) Admin/ Tchr/ Stdnt Mtg (ATS) Apology (APL) Behaviour Plan (BPL) Bus Suspension (BUS) Comm Service (CSR) Date of Admin Action Taken: Level of Severity (refer to chart) _____ Social Alienation (SAL) Counseling (CNS) Detention (DET) In-School Suspension (SIN) KidZone (KDZ) Mediation (MED) Outside Agency Referral (OAR)
Student Signature:
____ Verbal Agression (VAG) Parent Meeting (PAR) Phone Call Home (PHN) Playground Suspension (PLS) Removal of Privileges (PRI) Restitution (RES) Suspension (1-3) (S13)
___ Intimitation (INT)
____Other
Suspension (4-5) (S45) Suspension (> 5) (S>5) Think Paper / Form (TPF) Time Out (TMO) Verbal Warning (VWN)
Behaviour/Code
Comments:
Admin Signature:
Parent Signature: (Please sign and return the next day)
STUDENT BEHAVIOURS CHART
MILD
LEVEL 1 LEVEL 2 LEVEL 3
MODERATE
LEVEL 4 LEVEL 5
SEVERE
LEVEL 6
PHYSICAL AGRESSION (PAG)
• pushing (PUS) • spitting (SPI) • throwing rocks,
snowballs etc.(THR)
• kicking (KIC) • hitting (HIT)
• fighting (FIG) • stealing (STE)
• physical acts that are
demeaning and humiliating but not bodily harmful (eg. de-panting) (PHY)
• physical violence
against family or friends (PVL)
• inflicting bodily harm
(INF)
• locking in a closed or
• rough Play (RPL)
confined space (LOC)
SOCIAL ALIENATION (SAL)
• gossiping (GOS) • embarrassing (EMB) • setting up to look
foolish (SET) about (SPR)
• ethnic/gender slurs
(ETH)
• publicly humiliating
• spreading rumours
• setting up to take
blame (STB)
(eg. revealing personal information) (PUB) • excluding from group (EXC) • social rejection (SOR)
• manipulating social
order to achieve rejection (MAN)
• maliciously excluding
(MEX)
• malicious rumour
mongering (MRM)
VERBAL AGRESSION (VAG)
• mocking (MOC) • name calling (NAM) • dirty looks (DIR) • taunting (TAU) • teasing about clothing
or possessions (TCP)
• teasing about
appearance (TAA)
• intimidating phone
calls (IPC)
• verbal threats of
aggression against property or possessions (VTA)
• verbal threats of
violence towards others (VTV)
INTIMIDATION (INT)
• threatening to reveal
personal information (TRP)
• defacing property or
clothing (DPC) • playing a dirty trick (PDT)
• taking possessions
(eg. lunch, clothing, toys) (TPS)
• extortion (EXT)
• threat of using
coercion against family or friends (TUC)
• coercion (COE) • threatening with a
weapon (TWW)
• graffiti (GRA) • publicly challenging to
do something (PCD)
OTHER INAPPROPRIATE BEHAVIOURS
• unsafe actions (UNA) • non-application to
studies (NON)
• inappropriate internet
use (INA)
• lying (LYG) • disrespect (DIS) • inappropriate
language (ILA)
• non-compliance (NCO) • truancy (TRU) • bullying (BUL) • vandalism (VAN)
• smoking (SMO) • alcohol (ALC) • drugs (DRU)