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Elementary Discipline Referral Form 2015-2016 [Required ?aws marked with.
.l Roanin Walker 339334 01 Shadow Forest Elem?116
NAME STUDENT GRADE 
l2i?l H15 i2il lilo 9:45 am Pamela Slote
DATE OF OFFENSE 0F OFFENSE REFERRED BY

TEACHER ACTION PRIOR TO REFERRAL

Change Seating El Parent Contact EWaming El Detention ECounsalor Parent Conf IEI Team Cont Student Conf

 

TEACHER PARENT CONTACT: DPHONE DLETTER ECONFERENCE El EMAIL
or: conmcri

 

LOCATION: C a55mom

 

 

Roanin was refusing to do his work and got up on the short round table in the middle of the classroom and was repeatedly walking
around in a circle on top of the table. The classroom was cleared of all other students and Mrs. Lackey was called {9:45) Roanln
continued to walk in a Circle around the table. Mrs. Lackey became concerned for Roanin's safety. He appeared to be getting dizzy as
he continued. At 10:05 Mom was called. After mom was called and before she got to school Roanin stopped and walked up to the
of?ce with Mrs. Lackey.

INCIDENT REPORT

 

 

 

 

*Employee Signature: 9min Scots HE and to appropriate administrator]

ADMINISTRATOR ACTION

ReferraliOther Remarks:

 

 

  

 

ACTION TAKEN GUARDIAN 304640 Check box if muftiple
INCIDENT 

12?11l15 BY: Conference offenders were involved

[Date Detarrninedli

DISC OFFENSE 21 MIS?Miscellaneous Offenses

 

LOCATION cooE: 01-On Campus

 

 

 

 

 

 

 

 

 

 

 

 

 

DISCIPLINE ACTION CODE 0f days Total Days SCthule Scheduled REASON
[must enter at least one} 3135's!an Served Start Date End Date CODE
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[as-Isa partialday I ?l 12i11i15 

Discipline Date eSchooi Discipline

 

Mo Entry Modi?ed by:

 

 

 

-o Entry Date: 1'Entered by:

 

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ParentiGuardian Signature ilfanpnuhlai Date ?Administrator Signature *DatE

 

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