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The Louisiana School Behavior Report Form is an essential tool designed to document and address behavioral incidents occurring within the school environment. This report serves multiple purposes, primarily aimed at keeping parents and guardians informed about their child's behavior on campus, whether it takes place in the classroom, cafeteria, gymnasium, or during school-related activities. The form captures critical information, including the student's name, grade, and the specifics of the incident, such as the date, time, and location. It also includes various codes to classify the type of incident, the motivation behind the behavior, and any related influences, such as substance use or social dynamics. Furthermore, it outlines the actions taken by school staff in response to the incident, which may include referrals to counselors or disciplinary measures like detention or suspension. By encouraging open communication between schools and families, the Louisiana School Behavior Report Form aims to foster a safer and more supportive educational environment for all students.

Louisiana School Behavior Report Example

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)

Documents used along the form

The Louisiana School Behavior Report form serves as an essential tool for documenting behavioral incidents in schools. Alongside this form, several other documents may be utilized to provide a comprehensive overview of the situation. Below is a list of common forms and documents that often accompany the Louisiana School Behavior Report.

  • Incident Report Form: This document details the specifics of the behavior incident, including the time, location, and nature of the behavior. It is often used to record initial observations before further actions are taken.
  • Behavior Intervention Plan (BIP): A BIP outlines strategies and interventions designed to address specific behavioral issues. It is tailored to the individual student and aims to promote positive behavior change.
  • Minor Tracking Form: This form is used to track less severe behavioral incidents over time. It helps educators monitor patterns and identify when a more formal intervention may be necessary.
  • Parent Notification Letter: This letter informs parents or guardians about a behavioral incident involving their child. It typically summarizes the incident and outlines any actions taken by the school.
  • Disciplinary Action Form: This document records the disciplinary measures taken in response to a behavior incident. It includes details about suspensions, detentions, or other actions imposed by school officials.
  • Counseling Referral Form: When a student requires additional support, this form is used to refer them to a school counselor. It outlines the reasons for the referral and any relevant background information.
  • Restorative Practices Documentation: This form captures the processes and outcomes of restorative practices implemented following a behavior incident. It aims to repair harm and restore relationships within the school community.
  • Power of Attorney Form: For those needing legal documentation for financial matters, refer to our essential Power of Attorney resources to ensure your authority is clearly defined.
  • Behavioral Assessment: A behavioral assessment evaluates a student’s behavior in various contexts. It helps identify triggers and underlying issues that may contribute to behavioral challenges.
  • Emergency Action Plan: In cases of severe behavioral incidents, this plan outlines steps to ensure safety and appropriate responses. It includes procedures for staff and emergency contacts.

These documents work together to create a holistic approach to managing student behavior. By utilizing them, schools can better support students, address behavioral issues effectively, and foster a positive learning environment.

Key takeaways

  • The Louisiana School Behavior Report Form is essential for documenting behavior incidents that occur on school grounds or during school-related activities.

  • Parents and guardians receive this report to stay informed about their child's behavior and any disciplinary actions taken by school officials.

  • It is important for parents to discuss the incident with their child to understand its implications and to prevent future occurrences.

  • The form includes various codes to specify the incident's timing, location, and motivation, ensuring accurate reporting.

  • Teachers and school staff must indicate the actions taken in response to the incident, which may include referrals to counselors or other disciplinary measures.

  • School administrators also play a role in documenting actions taken, which may include detentions or suspensions.

  • All parties involved, including students and parents, should sign the report, affirming their awareness of the incident and the actions taken.