Discipline Checklist

(To be completed and attached to referral)

Teacher: Student: .
Occurrence

Date Discipline Step Student Signature

Warning to student about (behavior/s: _________________________________________)

1st

In Class Seating Change

2nd

Tier 1
Teacher Administered Detention/Mandatory PARENT CONTACT
3rd

Teacher Administered Detention/Mandatory PARENT CONTACT

4th

Teacher/Student/PARENT CONFERENCE
5th 6th

Team Conference with Student/PARENT CONTACT

Team Behavior Contract (Functional Behavioral Intervention Form Completed)

7th

Tier 2
Referral to Counselor/SAS as needed
8th
9th 10th 11th

Discipline Referral (as last resort)

REFERRAL

Tier 3
Referral to district Behavior Specialist.

Notes:

Continue on Reverse

Resources: PBIS World: www.pbisworld.com Behavior Doctor: www.behaviordoctor.org

Discipline Checklist