37

G.C. Burkhead Elementary School

521 Charlemagne Boulevard
Elizabethtown, KY 42701
270-769-5983
STUDENT DISCIPLINE REPORT

_____________________________ ________ _________ __________
Students Name Grade Date Time of Event

Location:
Classroom
Playground
Hallway
Cafeteria
Restroom
Gym
Library
Bus
Home
Field Trip
Specials/Related Arts
Other___________

Problem Behavior (Codes) Administrative Decision
Fighting (Fight,5001)
Physical Aggression (PAgg, 5001)
Disrespect (Disrespct, 127)
Defiance/Non-Compliance (Defiance, 1010)
Inappropriate Language-Profanity (M-Inapp Lan, 70)
Disruptive (M-Disruption, 2001)
Bullying (Bullying, 8001)
Harassment (Harass, 8002)
Property Damage (Prop dam, 005)
Forgery/Theft (Theft, 1009)
Lying/Cheating (Lying, 1001)
Skipping Class (Skip, 1004)
Technology Violation (Tech)
Inappropriate Display of Affection (Inapp affection, 60)
Sexual Behavior/Indecent Exposure (SBIE, 60/171)
Tobacco (Tobacco, 9003)
Drugs (Drugs, 1801)
Weapons (Weapons, 154)
Multiple Minor (attach minor form)
Other____________________
Reprimanded Warning
Referred to Counselor
Loss of privilege Comment:___________________
Office Time-Out _______ __________
Recreational Time _______ __________
Lunch Detention _______ __________
After School Detention _______ __________
In School Detention _______ __________
Bus suspension _______ __________
DATE TIME FRAME
Restitution (apologize/compensate) $ _________






Other______________________________________________
___________________________________________________
___________________________________________________

Others involved:
None Peers (attach names with note) Staff
Substitute Unknown
Possible Motivation:
Avoid Adult Avoid Peer Avoid Task Obtain Adult
attention Obtain Peer Attention Unknown Motivation

Description of Incident by Staff




____________________________________________________________________________________________________________________________________
Prior teacher actions: Changed seat Conf. with student Conf. with parent Referred to counselor Telephoned/emailed parent
Administrator Comments





Parent contacted by phone: Date __________ Time __________


_____________________ _______________________ ____________
Referring Teacher Principal Date