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Discipline Referral Form Template

Streamline your student disciplinary processes with ease

Managing student behavior can be challenging, but a well-structured Discipline Referral Form makes it simpler for educators like you. This template is designed to help teachers effectively communicate student misconduct to administrators, ensuring timely and appropriate disciplinary action. You can easily document incidents, maintain records of referrals, and promote accountability among students, all while complying with school policies. Plus, our WCAG-aligned labels ensure accessibility for everyone. Try the live template today!

Use this Template (FREE) Live Preview
Reporter full name
School or department
Reporter email
Reporter phone
Role
Teacher
Staff
Administrator
Counselor
Other
Please Specify:
Student full name
Student ID
Grade
Date of incident
Time of incident
Location of incident
Classroom
Hallway
Cafeteria
Playground
Bus
Restroom
Online/Virtual
Off campus
Other
Please Specify:
Type(s) of behavior
Please Specify:
Brief description of the incident
Perceived motivation
Attention
Avoid task
Avoid peers/adults
Obtain item/activity
Unknown/Unclear
Other
Please Specify:
Level of disruption to the learning environment
None
Low
Moderate
High
Severe
Was anyone injured?
Yes
No
If injuries occurred, describe injuries and care provided
Witness names (students or staff)
Were there witnesses?
Yes
No
Actions taken prior to referral
Please Specify:
Was the parent/guardian contacted prior to this referral?
Yes
No
Summary of parent/guardian communication
Contact method
Phone call
Email
In-person
Messaging app/Portal
Note sent home
Other
Please Specify:
Prior similar incidents for this student
No prior incidents
1 prior
2-3 priors
4+ priors
Unknown
Additional notes for the administrator
Recommended consequence or support
Please Specify:
Reporter signature
Date signed
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Paper art illustration representing a discipline referral form template for FormCreatorAI article

When to use this form

Use this form when you need to document serious or repeated behavior so administrators can act fast. It helps classroom teachers, deans, and counselors capture what happened, when, and what you tried. Typical cases include ongoing disruption after warnings, harassment, physical aggression, unsafe conduct, or a vaping incident. If you have been tracking patterns, reference your Behavior observation form to add context. If the incident happened with a sub, include notes or attach the Substitute teacher reporting form. Submitting this creates a clear record, prompts parent contact, and supports consistent consequences and timely interventions.

Must Ask Discipline Referral Questions

  1. What happened, where, and when?

    Specific details build a reliable record and reduce back-and-forth. Time and location also help identify patterns and supervision needs.

  2. Who was involved and who witnessed it?

    Names and roles make follow-up easier and protect student safety. Witnesses provide independent accounts and support fair decisions.

  3. What actions did you take immediately?

    Documenting redirection, calls home, or safety steps shows due diligence. It also prevents duplicated efforts and informs next responses.

  4. Has this behavior occurred before, and what supports have been tried?

    History shows whether the issue is isolated or a pattern that needs escalation. If you have notes, link or attach a Teacher observation form to add context.

  5. What outcome or next step do you recommend?

    Stating a clear recommendation (parent conference, detention, check-in) helps admins act quickly and transparently. If learning was impacted, reference a Student progress report form to document academic effects.

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