YSLETA INDEPENDENT SCHOOL DISTRICT DISCIPLINE

YSLETA INDEPENDENT SCHOOL DISTRICT
DISCIPLINE REFERRAL FORM
School:_______________________Student Id:_______________ Grade: ________ Date of Offense: _______________
Student Name:__________________________________________________________ Time of Incident: ____________
Home Phone: ___________________ Parent’s Work Phone: ___________________ Other Phone:__________________
Location of Incident: ____________________________________________ Referred By: _________________________
Teacher Parent Contacted/Date of Contact
Phone____________
Letter _______________
Conference _________________
E-mail __________
s Specific Statement of Problem: ______________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Office Use Only
Phone____________
Administrator Parent Contacted/Date of Contact
Letter _______________
Conference _______________
Police/SRO
Date: _____________ Time: _________
Officer(s): ___________________________ Citation
E-mail___________
PEIMS State Incident Number
Check if more
than one student
Case #:
Administrator Remarks:_____________________________________________________________________________
_______________________________________________________________________________________________
Date Action Ordered
_____ /_____ / _____
BIP Date: ___________________
Attach copy of the Manifestation Determination
In no case should the clerical staff choose the reason codes
01
02
03
04
05
06
07
Conduct N TEC
Sex Harass Stud
Sex Harass Empl
PE Dress Code
Name Calling
Disrespectful
Throwing Obj
23
24
25
27
28
29
30
Schl Gang Viol
Fight/Mutu Combat
Truant/Parent
Truant 10 Unex Abs
Truant Not Enrolled
Deadly Conduct
Off Camp NonTitle 5
46
47
48
49
50
51
52
08
09
10
11
12
13
14
15
16
17
18a
18b
Cheating/Forg
Theft
Hazing
Elect Device
Safety Rules
Psu Rx/Otc Drug
Tardies
Period Truancy
Dress Code Vio
Insubordination
Bullying Per
Bullying Cyber
Persistent Mis
On Campus
Crim Mischief
Emerg Plc Expul
PPUA Tobacco
31
33
34
35
36
37
38
39
40
41
42
43
Perm Teach Remov
Felony Conduct
PSU Cont Subs
PSU Alcohol
Abuse of Chem
Pub Lewd/IndExp
Off Camp Title 5
Terroristic Threat
Asslt Sch Staff
Asslt Non Sch Staff
False Alarm/Rpt
Retal Sch Empl
53
54
55
56
57
58
59
60
65
66
67
68
UEP Club
UEP Proh Weapon
Arson
Murder
Indecency Child
Agg Kidnapping
Agg Asslt Sch Staff
Agg Asslt Non Sch
Staff
Sex Asslt Emp/Vol
Sex Asslt NEmp/V
Felony Contr Subs
Felony Alcohol Vio
Aggrav Robbery
Manslaughter
CrimNegHomicide
Sex Off Ct Suprv
Sex Off N Ct Suprv
Cont Sex Ab Child
Breach Comp Sec
44
45
UEP Firearm
UEP Ill Knife > 5.5"
69
Persistent Mis DAEP
______________
Action Taken
To be filled out by Administrator only
Reason Code (check most severe code)
19
20
21
22
Time Left Office
504/ARD Date: ______________
Special Education/504
Action
Code(s)
Date Action(s)
Ordered
(PEIMS
Reportable)
(PEIMS Reportable)
Notified Attendance Office of
ISS and/or OSS
(Required for ISS and OSS)
Action
Start
Date
Action
Stop
Date
___/____/____
Date
Discipline Completion Date: ___________________
_________________________________________ ______________________________________________ ___________________________________________
Parent’s Signature
Distribution: Original: Record
Date
Student’s Signature
Copy: Teacher, Student's Parent, Counselor
Date
Administrator’s Signature
Date
Revised 08/2016