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JISD High Referral Form
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* Indicates required question
Name of Student
*
Your answer
Offense
*
Choose
Activating Safety Equipment
Arson
Assault/Battery Against School / Board Employee
Behavior Disruptive to the Learning Environment (i.e. talking)
Bomb Threat
Bus Referrals (Initial referrals are made by the bus driver)
Cafeteria Etiquette
Cheating/Copying Assignment/Plagiarism/Test: Using Notes Or Any Other Information Source During Test
Damaging Equipment
Disrespectful Speech / Action Towards School Personnel
Gross Disrespectful Speech / Action Towards School Personnel
Dangerous Behavior (Involves Danger / Harm To Others)
Dress Code Violation (Inappropriate Dress, Wearing Symbols not adhering to Dress Code, etc.)
Distribution of Drug / Alcohol
Drugs and/or Alcohol Possession, Use of/or Under The Influence
E-Cigarette, Vape, Juul, Other Vaping Tool, or Look alike
Electronics/Cell Phone Violation
Excessive Absences
Extortion
Failure to Follow Classroom/School Rules (Excessive)
Forgery
Gang Activity
Gambling
Harassment, Intimidation/Bullying, Student/Student, Student/Teacher
Insubordination; Lewd/Lascivious Behavior (Gross)
ISS Rule Violations
Malicious use of Electronic Device (Cyberbullying, Sexting, Video)
Misbehavior for a Substitute
Physical Contact Horseplay, Pushing, Running
Physical Contact (Fighting)
Physical Intimidation of Staff
Profanity, Foul Language, Obscene Materials or Inappropriate Gestures
Public Display of Affection (PDA)
Sexual Harassment
Stealing/Theft, Missing Property
Tardiness
Theft
Tobacco, Look Alikes or Cessation Materials
Trespassing
Truancy Skipping / Ditching
Unauthorized Entry Into/Use of School Facilities, Loitering Burglary
Vandalism/Graffiti/Defacing School Property
Violation of Activity Trip Rules; Violations of Any Motor Vehicle Regulations
Weapons/Knives
Other
What Have You Tried?
*
Redirect
Private Conference With Student
Parent Contact
Other:
Required
What would you like done?
*
Student Conference
Lunch Detention
ISS
OSS
DAEP
Additional Comments:
*
Your answer
Date:
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MM
/
DD
/
YYYY
Time:
*
Time
:
AM
PM
Location of incident:
*
Your answer
Referring Adult:
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Your answer
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