Blank Louisiana School Behavior Report PDF Form

Blank Louisiana School Behavior Report PDF Form

The Louisiana School Behavior Report Form serves as a crucial tool for documenting behavioral incidents that occur on school grounds or during school-related activities. This form not only informs parents and guardians about incidents involving their children but also details the disciplinary actions taken by school officials. It is essential for parents to engage in discussions with their children regarding these incidents to foster a safer and more supportive educational environment.

To ensure your child's well-being and to take appropriate action, please fill out the form by clicking the button below.

The Louisiana School Behavior Report Form serves as a vital tool for documenting incidents of inappropriate behavior occurring within school settings. This form is designed to inform parents and guardians about specific behavioral incidents that take place on campus or during school-related activities. It captures essential information, including the student's name, grade, and the location and time of the incident. Additionally, the form categorizes the type of incident and the motivations behind the behavior, allowing for a comprehensive understanding of the circumstances. It also includes sections for school officials to record any disciplinary actions taken, which can range from referrals to counseling or detention to more serious consequences like suspension or expulsion. The report emphasizes the importance of parental involvement in addressing behavioral issues, urging discussions between parents and students to prevent future occurrences. By systematically recording these incidents, the form aims to enhance the safety and well-being of all students within the educational environment.

Document Sample

LOUISIANA DEPARTMENT OF EDUCATION SCHOOL BEHAVIOR REPORT

In accordance with R. S. 17:416(A) the purpose of this report is to inform parents/guardians of a behavior incident on the school campus, in the classroom, cafeteria, gymnasium, auditorium, elsewhere at the school or during school-related activities, and of subsequent disciplinary action taken by school officials. Because this or other incidents may jeopardize the safety, well-being or education of other students, parents are urged to discuss the incident and possible implications with the student to prevent further occurrences.

Name of Student:

 

 

 

 

Phone:

Grade/Section:

 

 

 

 

 

 

 

 

 

 

 

Name of Teacher/Staff:

 

 

 

Teacher/Staff/Location:

 

 

 

 

 

 

 

 

 

 

 

Name of Principal:

 

 

 

 

School:

 

 

 

 

 

 

 

 

 

 

 

 

Check One:

 

 

 

 

Date of Incident:

Time:

Location:

Regular Education

504

Special Education

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time Code:

01 Before School on Grounds, 02 During Class, 03 Between Classes, 04 After Normal School Hours & Supervised,

 

05 To/From School, 06 At Bus Stop or Transfer Station, 07 During School Extracurricular/Assembly Event, 08

 

Recess, Club, Free Time, 09 Homeroom, 10 Breakfast/Lunch

 

 

 

Location Code:

01 Classroom, 02 Restroom, 03 Lunchroom, 04 Hallway, 05 Playground, 07 At Bus Stop or Transfer Station,

 

08 Parking Lot, 09 Locker Room, 10 Cell Phone, 11 Internet, 12 To or From School, 13 School Sponsored Event,

 

14 Home, 98 Offsite Program, 99 Other

 

 

 

 

 

 

 

 

 

 

 

 

INFRACTION/REASON CODES (Check all that apply)

01.

Willful disobedience

11.

02. Treats an authority with disrespect

03.

Makes an unfounded

12.

 

 

charge against authority

 

04.

Uses profane and/or

13.

 

obscene language

 

 

05. Commits immoral or vicious practices

06. Conduct or habits injurious to his/her associates

07.

Uses or possesses any

14.

 

controlled dangerous

 

 

substances governed by

 

 

the Uniform Controlled

 

 

Dangerous Substances

 

 

Law, in any form

 

08.

Uses or possesses

 

 

electronic vapor

 

 

products, tobacco,

 

 

lighter, or matches

15.

09.

Uses or possesses

 

 

alcoholic beverages

16.

10.

Disturbs the school or

 

habitually violates any rule

Cuts, defaces, or injures

17.

Violates traffic and

36.

Cyber Bullying

any part of public school

 

safety regulations

 

(*complete Bullying Form)

buildings/vandalism

18.

Leaves school premises

37.

False Alarm/Bomb Threat

 

Writes profane and/or

 

or classroom without

38.

Forgery

obscene language or

 

permission

 

39.

Gambling

draws obscene pictures

19.

Is habitually tardy and/

 

40.

Public Indecency

Possesses weapon (s) as

 

or absent

defined in Section 921 of

20.

Takes another’s property

41.

Obscene behavior or

Title 18 of the U.S. Code.

 

or possessions without

 

Possession of Obscene/

*Use of code 13 requires

 

permission

 

Pornographic Material

additional submission of

21.

Commits any other

42.

Unauthorized use of

the Weapon Type code.

Possesses firearms (not

 

serious offense

 

Technology

30.

Discharge or use of

43.

Improper dress

prohibited by federal

law), knives, or other

 

weapon(s) prohibited by

44.

Academic dishonesty

implements, which may

 

federal law

45.

Trespassing Violation

be used as weapons,

31.

Possesses pocket knife

46.

Failure to Serve Assigned

the careless use of which

 

or blade cutter with a

might inflict harm or

 

blade length < 2 ½”

 

Consequence

injury (Excludes pocket

33.

Use of OTC medication

47.

Misusing Internet/

knives with a blade length

 

Violates electronic/

< 2 ½“ - refer to code 31).

 

in a manner other than

 

 

 

technology policy

 

prescribed or authorized

 

 

 

 

Throws missiles liable to

 

 

 

34.

Possession of Body Armor

48.

Sexual Harassment

injure others

 

 

49.

False Report

Instigates or participates

35.

Bullying/Harrassment

 

 

in fights while under

 

(*complete Bullying Form)

50.

Crime of Violence

school supervision

 

 

 

(per R.S. 14:2B)

REMARKS/DESCRIPTION OF INCIDENT:

(REVISED 6/20/2023)

LOUISIANA DEPARTMENT OF EDUCATION SCHOOL BEHAVIOR REPORT

ACTION(S) TAKEN BY TEACHER OR OTHER SCHOOL EMPLOYEE

The student named above is hereby reported for inappropriate behavior as indicated in this report. This is the student’s 1st

2nd 3rd 4th 5th

(circle one) or other

 

cumulative behavioral referral(s). I have taken the following action(s):

 

 

011

Referred to Office

022

Therapeutic Removal

030

Restorative Practices Implemented

012

Referred to Counselor

025

Intervention Room

173

Conference with Parents or Guardians

013

Referred to Social Worker

080

Assigned Remedial Work

175

Conference with Principal

014

Referred to SBLC

120

Student Conference

999

Other Action

 

 

018

Secondary Referral (PBIS)

140

Student Reprimand

 

 

 

 

 

019

Tertiary Referral (PBIS)

160

Loss of Privileges

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Parent/Guardian? Y

N

Date:

Time:

 

Phone Call

Letter

Conference Date:

 

Time:

 

 

 

 

 

 

 

 

 

RECOMMENDATION(S) BY TEACHER OR OTHER SCHOOL EMPLOYEE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of School Employee:

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

ACTION(S) TAKEN BY SCHOOL ADMINISTRATOR

The student named above is hereby reported for inappropriate behavior as indicated in this report. This is the student’s 1st 2nd

3rd

4th

5th

(circle one) or other

 

cumulative behavioral referral(s). I have taken the following action(s):

 

 

 

 

 

 

000

No Action – only use if no

 

 

 

 

 

014

Referred to School Building Level

080

Assigned Remedial Work

 

 

 

 

reportable action was taken

 

 

 

 

 

Committee (SBLC)

 

 

 

 

 

 

 

 

 

120

Student Conference Date:

 

 

 

001

Expulsion Recommendation

 

 

 

016

Court Referral Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

140

Student Reprimand

 

 

 

 

 

 

002

Suspension Out of School

 

 

 

 

 

017

Enforcement Referral (Arrest

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

160

Loss of Privileges

 

 

 

 

 

 

 

from

 

to

 

 

 

 

 

 

 

 

 

Resulted Y N)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

173

Conference w/ Parents or

 

 

 

004

Suspension In School from

 

 

 

to

 

020

TOR (Time Out Room)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Guardians on:

 

 

 

 

 

 

 

006

Suspension Alternative Site

 

 

 

030

Restorative Practices Implemented

 

 

 

 

 

 

 

 

 

 

175

Conference w/ Principal on:

 

 

 

 

from

 

to

 

 

 

 

 

 

 

040

In School Detention from

 

to

 

 

 

 

 

 

 

 

 

 

 

180

Corporal Punishment (if checked,

012

Referred to Counselor

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

043

After School Detention from

 

 

 

 

to

 

 

 

complete “Corporal Punishment”

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

013

Referral to Social Worker

 

 

 

 

 

045

Weekend Detention from

 

to

 

Incidence Checklist)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

999

Other Action(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Perpetrator: Serious Bodily Injury

 

Y

 

 

N

Medical Treatment Y

N Victim: Serious Bodily Injury

Y N Medical Treatment

 

Y

N

 

 

 

 

 

 

 

 

 

 

 

 

 

Contact Parent/Guardian? Y

 

 

N

Date:

Time:

Phone Call

 

 

 

Letter

Conference Date:

Time:

 

 

 

 

 

 

 

 

 

 

 

SIS Primary Infraction/Reason Code Entered:

 

Signature of Principal:

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMMENTS BY STUDENT AND/OR PARENT/GUARDIAN:

Signature of Student:

Signature of Parent/Guardian:

Current Date:

Check appropriate blocks as copies of the document are supplied:

Parent/Guardian

School’s Pupil File

Employee Filing this Report

Principal

*NOTE: The principal shall return a completed copy of this form to the staff

member who initiated the referral within 48 hours

(excluding non-work days) of the time it was submitted to the principal.

**Attachments: Provide copies of all documents related to the behavior of the student named above and prepared by the employee submitting this referral.

(REVISED 6/20/2023)

File Specifics

Fact Name Details
Governing Law The Louisiana School Behavior Report Form is governed by R.S. 17:416(A).
Purpose This form informs parents or guardians about behavior incidents occurring on school grounds or during school-related activities.
Incident Reporting It documents incidents that may affect the safety, well-being, or education of students.
Incident Locations Incidents can occur in various locations, including classrooms, cafeterias, and during extracurricular events.
Behavior Codes The form includes specific codes for types of behaviors, such as serious offenses, substance possession, and weapons.
Parental Involvement Parents are encouraged to discuss incidents with their children to prevent future occurrences.
Actions Taken School officials must document actions taken in response to the behavior incident, including referrals and disciplinary measures.
Documentation Requirements A completed copy of the form must be returned to the initiating staff member within 48 hours, excluding non-work days.

How to Use Louisiana School Behavior Report

Completing the Louisiana School Behavior Report form requires careful attention to detail. This form serves as a communication tool between the school and the parents or guardians regarding behavioral incidents. To ensure that the information is accurately recorded, follow these structured steps.

  1. Fill in the Student Information: Write the student’s full name, phone number, and grade or section at the top of the form.
  2. Provide Teacher and School Details: Enter the name of the teacher or staff member involved, the room number or location, and the principal’s name.
  3. Select Education Type: Check the appropriate box indicating whether the student is in Regular Education, 504, or Special Education.
  4. Document the Incident: Write the date and time of the incident, and specify the location where it occurred.
  5. Choose Time and Location Codes: Select the relevant time code and location code from the provided lists to categorize the incident accurately.
  6. Identify Motivation and Influences: Check the motivation code that best describes why the behavior occurred. Also, indicate any related influences such as drugs or alcohol.
  7. Assess Injury and Medical Treatment: Circle 'Yes' or 'No' for both the perpetrator and victim regarding serious bodily injury and medical treatment.
  8. Mark Behavior Codes: Check all relevant boxes for the primary incident or reason codes that apply to the behavior being reported.
  9. Describe the Incident: In the remarks section, provide a detailed description of the incident, including any relevant context or background information.
  10. Record Actions Taken: Indicate the actions taken by the teacher or other school employees regarding the behavior. Circle the number of cumulative behavioral referrals the student has.
  11. Contact Parent/Guardian: Note if the parent or guardian was contacted, including the date and time of the communication method used.
  12. Recommendations: Write any recommendations made by the teacher or school employee concerning the incident.
  13. Principal's Actions: If applicable, document the actions taken by the school administrator, including any recommendations for further action.
  14. Student and Guardian Signatures: Have the student and parent or guardian sign the form, along with the current date.
  15. Check Copy Distribution: Indicate which copies of the document are supplied for the parent/guardian, school’s pupil file, and employee filing the report.

After completing the form, it should be submitted to the principal, who will return a completed copy to the initiating staff member within 48 hours. This process ensures that all parties are informed and that appropriate follow-up actions can be taken.

Your Questions, Answered

What is the purpose of the Louisiana School Behavior Report form?

The Louisiana School Behavior Report form is designed to inform parents or guardians about behavior incidents that occur on school grounds or during school-related activities. It serves as a communication tool between the school and home, ensuring that parents are aware of any issues that may affect their child's safety, well-being, or educational experience. The form also outlines the disciplinary actions taken by school officials in response to the incident.

What information is required on the form?

The form requires various details to provide a comprehensive overview of the incident. Key information includes:

  • Name of the student
  • Contact phone number
  • Grade or section of the student
  • Name of the teacher or staff involved
  • Location and time of the incident
  • Type of education program (Regular, 504, or Special Education)
  • Motivation for the behavior
  • Details of any injuries or medical treatment
  • Description of the incident and actions taken by school personnel

How should parents respond after receiving the report?

Upon receiving the Louisiana School Behavior Report, parents are encouraged to discuss the incident with their child. Open communication can help address the behavior and its implications. Parents should consider the following steps:

  1. Review the details of the incident as reported.
  2. Talk with your child about their perspective and feelings regarding the incident.
  3. Discuss the importance of appropriate behavior and its impact on their education and relationships.
  4. Collaborate with school officials if necessary, to develop a plan to prevent future incidents.

What types of disciplinary actions can be taken?

The form outlines a variety of disciplinary actions that school officials may implement based on the severity and nature of the incident. Some common actions include:

  • Referred to the office or counselor
  • In-school or out-of-school suspension
  • Detention, either after school or on weekends
  • Loss of privileges
  • Restorative practices

Each action aims to address the behavior while also providing support to the student to encourage positive change.

What happens if a student receives multiple behavior reports?

When a student receives multiple behavior reports, it indicates a pattern of behavior that may require additional intervention. The form allows school officials to track the number of cumulative referrals. Depending on the frequency and severity of incidents, schools may take more serious actions, such as:

  • Increased communication with parents or guardians
  • Development of a behavior intervention plan
  • Referral to specialized support services

Ultimately, the goal is to support the student in making better choices and improving their behavior.

Common mistakes

  1. Incomplete Student Information: Failing to fill out all required fields such as the student’s name, grade, and teacher’s name can lead to confusion and delays in processing the report.

  2. Incorrect Incident Date or Time: Entering the wrong date or time of the incident can affect the investigation and response from school officials.

  3. Missing Location Codes: Not selecting the correct location code can result in misunderstandings about where the incident took place, which is crucial for context.

  4. Omitting Motivation Codes: Failing to check the motivation codes can prevent staff from understanding the underlying reasons for the behavior, making it harder to address the issue effectively.

  5. Inaccurate Reporting of Actions Taken: Not clearly stating the actions taken by the teacher or school employee can lead to miscommunication about how the situation was handled.

  6. Neglecting Parent/Guardian Contact: Forgetting to document the contact made with the parent or guardian can result in a lack of follow-up and support for the student.

Documents used along the form

The Louisiana School Behavior Report form is a vital document for tracking and managing student behavior incidents in schools. However, it is often accompanied by several other forms and documents that help provide a comprehensive view of a student's behavior and the actions taken. Below is a list of these additional forms, each serving a unique purpose in the behavior management process.

  • Classroom Minor Tracking Form: This form is used by teachers to document minor behavioral incidents that occur in the classroom. It helps identify patterns in student behavior over time and can inform interventions.
  • Behavior Intervention Plan (BIP): A BIP outlines specific strategies and interventions tailored to address a student's behavioral challenges. It is developed collaboratively by educators, parents, and specialists.
  • Incident Report Form: This document provides a detailed account of a specific incident involving a student. It includes information about what occurred, who was involved, and any immediate actions taken.
  • Parent Communication Log: This log is used to record interactions with parents regarding their child's behavior. It ensures that parents are kept informed and can contribute to behavior management efforts.
  • Referral to Counseling Form: When a student is referred for counseling, this form documents the reasons for the referral and outlines the expected outcomes of counseling sessions.
  • Disciplinary Action Report: This report details the disciplinary actions taken against a student following a behavior incident. It serves as a formal record for school administrators and can be referenced in future incidents.
  • Behavioral Assessment: Conducted by a school psychologist or counselor, this assessment evaluates a student's behavior and identifies potential underlying issues that may be contributing to behavioral problems.
  • Restorative Practices Form: This form is used to document the implementation of restorative practices, which focus on repairing harm and restoring relationships rather than simply punishing the student.

These documents work together to create a well-rounded approach to behavior management in schools. By utilizing them effectively, educators can foster a supportive environment that promotes positive behavior and addresses challenges proactively.

Similar forms

The Louisiana School Behavior Report form shares similarities with the Incident Report form commonly used in workplaces. Both documents serve to formally document occurrences of inappropriate behavior or incidents that may disrupt the environment, whether in a school or workplace setting. Each report typically includes details such as the date, time, and location of the incident, as well as descriptions of the behavior observed. Furthermore, both forms often require the identification of individuals involved, including witnesses, and may outline any actions taken in response to the incident. This structured approach helps ensure that all relevant information is captured, providing a clear record for future reference.

Another document that resembles the Louisiana School Behavior Report form is the Disciplinary Action Notice. This notice is used by schools and organizations to inform individuals about the consequences of their actions. Like the behavior report, it details the nature of the incident, including specific behaviors that led to disciplinary measures. The Disciplinary Action Notice typically outlines the steps taken by authorities, such as warnings or suspensions, and may also include recommendations for future behavior. Both documents aim to communicate the seriousness of the situation to the involved parties, promoting accountability and encouraging reflection on the behavior in question.

The Student Conduct Report is another document that parallels the Louisiana School Behavior Report form. This report focuses on documenting student behavior in relation to established conduct codes within educational institutions. It includes similar elements, such as the date and location of the incident, the behavior exhibited, and any disciplinary actions taken. The Student Conduct Report is often utilized to track patterns of behavior over time, providing educators and administrators with insights into a student’s conduct history. Both forms emphasize the importance of maintaining a safe and respectful environment for all students.

In addition, the Bullying Incident Report shares common features with the Louisiana School Behavior Report form. This report specifically addresses incidents of bullying, providing a detailed account of the event, including the individuals involved and the context of the behavior. Like the behavior report, it aims to document the incident thoroughly to ensure appropriate follow-up actions are taken. Both documents prioritize the safety and well-being of students, encouraging open communication between school officials, parents, and students to address and prevent further occurrences.

Lastly, the Behavioral Referral Form used in many schools is quite similar to the Louisiana School Behavior Report form. This form is utilized to refer a student to a counselor or administrator for behavioral issues. It captures essential information about the incident, including the nature of the behavior and any prior interventions attempted. Both forms emphasize the importance of addressing behavior in a constructive manner, often leading to discussions about potential solutions and support for the student. By documenting these incidents, schools can work collaboratively with families to foster positive behavior changes.

Dos and Don'ts

When filling out the Louisiana School Behavior Report form, there are specific actions to take and avoid. Adhering to these guidelines will ensure clarity and accuracy in reporting.

  • Do provide complete and accurate information about the incident.
  • Do include the date, time, and location of the incident.
  • Do specify the names of all individuals involved, including the student and staff.
  • Do check all relevant boxes for codes related to the incident.
  • Don't leave any sections blank unless instructed otherwise.
  • Don't use vague language; be specific about the behavior and context.
  • Don't forget to sign the report where required.
  • Don't submit the report without reviewing it for errors or omissions.

Misconceptions

Misconception 1: The Louisiana School Behavior Report form is only for serious incidents.

This form is used for a variety of behavioral incidents, not just the severe ones. It addresses minor issues as well, helping schools track and manage all types of behavior. By reporting even small incidents, schools can work towards preventing bigger problems in the future.

Misconception 2: Parents do not need to be involved in the process.

Parents are a crucial part of this process. The form is designed to inform them about incidents involving their child. This communication allows parents to engage in discussions with their child about behavior and its consequences, fostering a supportive environment for improvement.

Misconception 3: The report only serves as a punishment tool.

The primary goal of the Louisiana School Behavior Report form is not punishment, but rather to promote understanding and improvement. It documents incidents to help educators identify patterns and provide necessary support to students. The focus is on corrective action and guidance.

Misconception 4: All incidents reported lead to severe disciplinary actions.

Not every reported incident results in severe consequences. The form outlines a range of actions that can be taken, depending on the nature of the behavior. Many responses aim to educate and support the student rather than simply discipline them. This approach can lead to more positive outcomes for students in the long run.

Key takeaways

  • The Louisiana School Behavior Report form serves as an important communication tool between schools and parents. It documents behavioral incidents that occur on campus or during school-related activities.

  • When filling out the form, it's essential to include detailed information about the incident. This includes the date, time, and location, as well as the motivations behind the behavior and any related influences.

  • Parents are encouraged to discuss the incident with their child. Understanding the context can help prevent future occurrences and support the child's emotional and educational needs.

  • The form includes various codes to classify the incident, such as the type of behavior and the actions taken by school staff. Accurate coding is crucial for proper record-keeping and analysis.

  • Finally, after the form is completed, it must be returned to the initiating staff member within 48 hours. This ensures timely communication and follow-up regarding the student's behavior and any necessary interventions.