The Washington Oak T.E.A.C.H Program

T.E.A.C.H. Links Land's End Wallaby clothes Really, what is a wallaby? PBIS Information T.E.A.C.H. Rewards T.E.A.C.H. Matrix WO Discipline Form Radical Recess Rules School Info Page Washington Oak Home Page

Washington Oak School Discipline Form NAME:________________________ DATE:___________ TIME:________ TEACHER:_____________________ GRADE:     PreK   K   1   2    3   4   5 REFERRING STAFF:______________              LOCATION: P.E. Art Music Library Classroom Other             Playground Cafeteria Bathroom Arrival/Dismissal Hallway Problem Behavior Possible Motivation Consequence Minor    Inapropriate language    Physical contact    Defiance    Disruption    Property misuse    Other Major    3 minors in 1 week    Abusive language    Fighting/Physical agression    Overt defiance    Harrassment/tease/taunt    Disruption    Other Obtain peer attention Obtain adult attention Obtain items/activities Avoid peer(s) Avoid adult(s) Avoid task or activity Other:___________ Others Involved None Peers Staff Teachers Substitute Unknown Other Loss of privilege Time in office Conferebce with student Parent contact Individualized instruction In-school suspension (___Hours/Days) Out of school suspension (___Hours/Days) Loss of Recess (10 minutes per minor) Reflection sheet Check as many consequences as appropriate (i.e. Loss of recess & Reflection sheet) Number each minor as they occur so students may only receive one Discipline Form per day (unless they commit a major with no any previous minors) This page was last updated on Monday, May 11, 2009 10:31 PM