RHS Discipline Referral Form
Referrals will be immediately emailed to the RHS office.
Reporting Staff Name
*
First Name
Last Name
Date & Time of Incident
*
/
Month
/
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Student Name
*
First Name
Last Name
Student's Academy
Please Select
BEI
DEM
HHP
Student Grade
Please Select
Freshman
Sophomore
Junior
Senior
Reason(s) for Notice:
*
Bullying
Calling Names
Cell Phone/Electronic Device Violation
Cheating/Plagiarism
Damage to School Property
Disrespect of Staff
Disrespect of Student
Disruption
Disruptive with Sub
Dress Code Violation
Excessive Tardies
Fighting
Graffiti
Harassment
Insubordination
Intimidation
Larceny/Theft
Left Class w/o Permission
Left Grounds w/o Permission
No Show Detention
No Show Extended Detention
Parking/Driving
Physical Assault
Profanity
Pushing/Shoving
Refusal to Identify Self
Sexual Harassment
Tardies
Technology Misuse
Threatening Behavior
Throwing Objects
Unacceptable Behavior
Verbal Assault
Other (indicate in Notes)
Notes
Action Prior to Notice:
Please Select
Changed Student's Seat
Consulted Counselor
Had Conference with Parent
Had Conference with Student
Sent Previous Notice(s)
Other (indicate in Notes)
Present Action and Recomendation(s)
*
Documentation Purposes
After School Detention*
Additional Administrative Action Requested
Suspension (assigned by administration only)
Saturday School (enter date and assignments below)
Notes: Briefly describe what happened:
*
Submit
Should be Empty: