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Student Name

Student ID

Student DOB

John Doe



Infraction Details:
Date: 2/12/15

Time: 12:00



Location of Incident: Cafeteria


Bob Brown, head custodian; Dean McDean, Dean of Students

On Thursday, February 12, 2015, John Doe, a seventh [7] grade student attending Swainston Middle
School was insubordinate to a staff member during lunch period at Swainston Middle School. John Doe
[Grade 7 #123456] was involved in a milk throwing incident, which led to him throwing a broom at head
custodian Jan Janitor. John Doe [Grade 7 #123456] was placed on RPC-T on Thursday, February 12,
2015 and his mother, Suzy Doe, was notified regarding the RPC.

Over the past year, John Doe [Grade 7 #123456] has been seen seven [7] times in the Deans Office.
These incidences include: defiance [1]; unacceptable school behavior [1]; and insubordinate [5]. The
latest insubordinate referral resulted in a required parent conference. Interventions have included:
detentions, conferences with staff, and in-house suspensions. Despite the interventions employed by
Swainston Middle School, John Doe's [Grade 7 #123456] disregard of the school rules and regulations
has escalated.
A Required Parent Conference was held on February 18, 2015 with John Doe [Grade 7 #123456], John
Does mother, Suzy Doe, and Dean McDean, Dean of Students. At the conference, Mrs. McDean
informed John Does mother, Suzy Doe that the administration of Swainston Middle School was
recommending behavior school due to John Doe's insubordination in a Swainston Middle School
towards teacher and staff and his continued disregard of school rules and regulations.
The levels of due process were explained to John Doe's mother, Suzy Doe, by Dean McDean, Dean of
Students at Swainston Middle School on February 18, 2015. John Does mother, Suzy Doe, AGREED
with the recommendation and signed the due process document accordingly. A homework request was
made and John Doe's mother, Suzy Doe was informed of the procedures for retrieving the homework
while John Doe [Grade 7 #123456] was suspended pending the behavior school referral process.
The administration of Swainston Middle School has determined that John Doe's behavior is
contradictory to the policies and regulations governing the students of the Clark County School District
and Swainston Middle School. Accordingly, the administration of Swainston Middle School is
recommending that John Doe D.O.B. 6-02-2002, be referred for alternative education to Jeffery
Behavioral School in the Clark County School District for violation of CCSD Regulation 5141.1,
specifically item VII, and subsection V: B (Verbal Abuse, Intimidation, or Cyber-Bullying) and E
(Violations of Authority and Behavioral Guidelines).

Prepared By: ________________________________________ Title: ___________________________

Print Name

Signature: __________________________________________ Date: ___________________________


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SUMMARY (Continued):

Signature: __________________________________________ Date: ___________________________