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									Module 7: Office Discipline
   Referral Forms &
  Classroom Behavior
    Tracking Forms
  Office Discipline Referral (ODR)
• In formatting the referral form, you must make sure to
  answer the following questions:
            Who          Why
            What         When
• Clarity on the referral form takes the guess work out of
  the data entry person’s job
• Data will be more reliable and accurate as
  judgement calls are minimized

    Compatible Referral Form
The following categories must be included on
                  the form:

•Student’s Name                 •Problem Behavior
•Date                           •Possible Motivation
•Time of Incident               •Others Involved
•Student’s Teacher (optional)   •Administrative Decision *
•Student’s Grade Level          •Other Comments
•Referring Staff
                                •No more than 3 extra
•Location of Incident           info.
                                * Will be discussed in a future
     Characteristics of a SWIS III
     Compatible Referral Form
• Student’s Name          •Problem Behavior
• Date                    •Possible Motivation
• Time of Incident        •Others Involved
• Student’s Teacher       •Administrative
  (optional)              Decision*
• Student’s Grade Level   •Other Comments
• Referring Staff         •No more than 3 extra
• Location of Incident    info.
                          * Will be discussed in a
                          future module
         Developing the ODR

Challenges:                  Solutions:
•   County required form     •   Create a
•   The form is not filled       supplemental form
                                 with additional
    out correctly
                             •   Re-train faculty or
                                 return to faculty to fill
                                 out completely before
    Module 7: Office
Discipline Referral Forms
and Classroom Behavior
    Tracking Forms.
Minor Infraction Report

Student Name (Last, First, Middle Initial)   Grade      Race Date             Time         Referring Teacher
HR Teacher

     Incident Location: (Circle One)                             Possible Motivation: (Circle One)
1. Bat hroom/Restroom               9. Library                   1. Avoid Adult            5. Obt ain Adult Attention
2 Bus Ramp                          10. Office                   2. Avoid Peers            6. Obtain Items/Activities
3. Cafeteria                        11. Bus #___                 3. Avoid Task/Activities 7. Obtain Peer Attention
4. Classroom                        12. Other                    4. Don’t Know             8. Other
5. Commons/Common Area              13. Playground               Expectation Violated: (Circle One)
6. Gymnasium                                                     Respectful Responsible Ready t o Learn
Incident Type: (Circle One)
1. Dress Code                   6. Harassment/Tease/Bully        Incident Description:_________________________
2. Inappropriate Lang.       7. Property Damage
3. Disrupt ion                  8. Forgery/Theft                   ____________________________________________
4. Defiance/Disrespect       9. Chewing Gum
5. Lying/Cheating           10. Other ____________               _____________________________________________
 Intervention: (All that Apply)
1. Student Conference______ 6. Phone Parent_______               10. Time Out                          14. Student
     Cont ract
2. Re-teach Expectation             7. Peer Mediation______      11. Loss of Class Privilege           15.
3. Seat ing Change                  8. Parent Conference______   12. Refer to Guidance
4. Lett er t o Parent______         9. Curricular Modification   13. Sent to Rm. #__________

(Please sign and return to school)
Parent Signature_______________________________
Goal of the Tracking Form

Collect data that are necessary to identify
 effective ways of changing inappropriate
 classroom behavior (minor) before it
 results in an office discipline referral

  Classroom Tracking Forms

• Classroom behaviors take up considerable
  amounts of teacher time that could be
  better spent on instruction

• Forms assist in identifying the pattern of
  behavior and determining interventions that
  will be most effective for the student(s)

•When does a recurring behavior become a major?
   • Same behavior (3 minors = 1 major)
   • From one particular teacher
   • Suggested time frame ( 3minors within 4 weeks)

•Used as a tool to identify patterns of behavior
   • When are the behaviors occurring? (math, transition)
   • What are the recurring behaviors?
   • What are the classroom interventions that have been used? Are these
      interventions working or does something else need to be utilized?
   • Why is the behavior occurring? (motivation, example: Johnny rips up his
      math sheet and is given time out and gets out of his work. He always
      gets to avoid doing his math work)
            Reflection Questions
Answer these questions about your SW-PBS team:
1. Does your referral form have the following. "Yes" or "No" for each part.
   a. Student's Name?
   b. Student's Ethnicity?
   c. Grade Level?
   d. Date?
   e. Time?
    f. Referring Staff?
    g .Incident Type?
    h. Location?
    i. Motivation?
    j. Others Involved?
    k. Administrative Decision?

          Reflection Questions
Answer these questions about your SW-PBS team:
2. Does the staff at your school consistently fill out the form
    correctly? If no, provide some suggestions for ways to retrain
    the staff.
3. Does your school use a minor or classroom behavior tracking
4. If you answered "Yes" to question 3:
     -are staff consistently using the form?
     -are staff correctly using the form?
If you answered "No" to either part of 4a. What are some
    suggestions for retraining your staff on using the minor form?

You have completed Florida's PBS Project
   School-wide Positive Behavior Support
   Module 7: Office Discipline Referral Forms
   and Classroom Behavior Tracking Forms.
If you would like a certificate of completion
   please print this page.


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