Official Louisiana School Behavior Report Template in PDF Fill Out My Document Online

Official Louisiana School Behavior Report Template in PDF

The Louisiana School Behavior Report Form is a document designed to inform parents or guardians about behavior incidents that occur on school premises or during school-related activities. This form outlines the nature of the incident, the actions taken by school officials, and any subsequent disciplinary measures. Parents are encouraged to engage in discussions with their children regarding the incident to foster understanding and prevent future occurrences.

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Structure

Document Overview

Fact Name Description
Purpose The Louisiana School Behavior Report Form is designed to inform parents or guardians about behavior incidents occurring on school grounds or during school-related activities.
Governing Law This report is mandated by Louisiana Revised Statutes R. S. 17:416(A), which outlines the requirements for reporting student behavior incidents.
Incident Locations Behavior incidents can occur in various locations, including classrooms, cafeterias, gymnasiums, and during extracurricular activities.
Motivation Codes The form includes motivation codes to help identify why a student may have acted out, such as avoiding adults or seeking peer attention.
Actions Taken Teachers and school staff must document the actions taken in response to the behavior, which may include referrals to counselors or disciplinary actions.
Follow-Up Requirement The principal is required to return a completed copy of the report to the initiating staff member within 48 hours, ensuring timely communication.

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Detailed Steps for Writing Louisiana School Behavior Report

Completing the Louisiana School Behavior Report form is essential for documenting behavior incidents and the actions taken. Follow these steps to ensure accurate and thorough completion of the form.

  1. Fill in the Student Information: Enter the student's name, phone number, grade/section, and the name of the teacher or staff member involved.
  2. Provide Location Details: Specify the room number or location where the incident occurred and the name of the principal.
  3. Select Educational Status: Check the appropriate box for Regular Education, 504, or Special Education.
  4. Document Incident Date and Time: Write the date and time of the incident. Choose the time code that best describes when the incident took place.
  5. Indicate the Location Code: Select the location code that corresponds to where the incident occurred.
  6. Identify the Motivation Code: Choose the motivation code that applies to the student's behavior.
  7. Check Related Influences: Indicate any relevant influences such as drugs, alcohol, or bias by checking the appropriate boxes.
  8. Circle Yes or No: For both the perpetrator and victim, indicate whether there was serious bodily injury or medical treatment required.
  9. Mark Behavior Codes: Check all applicable behavior codes that describe the incident.
  10. Provide a Description: Write a detailed description of the incident in the remarks section.
  11. Actions Taken by Teacher: Circle the number of the cumulative behavioral referral and list the actions taken by the teacher or other school employee.
  12. Contact Parent/Guardian: Note the date and time of contact with the parent/guardian, and specify the method of communication.
  13. Recommendations: Include any recommendations made by the teacher or school employee.
  14. Signature of School Employee: The school employee must sign and date the form.
  15. Actions Taken by School Administrator: Document the actions taken by the administrator, including the number of cumulative referrals.
  16. Contact Parent/Guardian Again: Record the date and time of any additional contact with the parent/guardian.
  17. Student and Parent/Guardian Comments: Provide space for comments from the student and/or parent/guardian, and include their signatures.
  18. Check Copies: Indicate which copies of the document are being supplied.

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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)

Misconceptions

Misconceptions about the Louisiana School Behavior Report form can lead to confusion for parents, educators, and students. Understanding these misconceptions is crucial for ensuring effective communication and appropriate responses to behavioral incidents. Below are six common misconceptions:

  • The report is only for serious incidents. Many believe the form is only necessary for severe behavior issues. In reality, it is used for a wide range of incidents, including minor infractions, to document patterns of behavior.
  • Parents are not involved in the process. Some think that the report is an internal school document that parents do not need to see. However, the form is designed to inform parents about incidents and encourages them to discuss the matter with their child.
  • The report leads to automatic punishment. There is a misconception that filing a report guarantees disciplinary action. The form serves primarily as a communication tool, and the actions taken depend on the circumstances and school policies.
  • All incidents are treated the same. Not every incident results in the same consequences. The report includes various codes and categories that help educators assess the context and severity of each situation before deciding on appropriate actions.
  • The report is only for classroom behavior. Some people think the form is limited to classroom incidents. In fact, it covers behavior occurring in multiple locations, such as the cafeteria, gym, or during school-sponsored events.
  • Filing a report is the only step needed. There is a belief that simply completing the report resolves the issue. However, it is just one part of a broader process that includes communication with parents, possible interventions, and follow-up actions.

Addressing these misconceptions can help foster a better understanding of the Louisiana School Behavior Report form and promote a collaborative approach to student behavior management.

Documents used along the form

The Louisiana School Behavior Report form is a crucial document for addressing 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. Here’s a brief overview of some commonly used documents alongside the behavior report.

  • Classroom Minor Tracking Form: This form tracks minor behavior incidents that occur in the classroom. Teachers document each incident, providing a record that can help identify patterns and inform future interventions.
  • Behavior Intervention Plan (BIP): A BIP outlines specific strategies and supports tailored to a student’s unique behavioral needs. It aims to improve the student’s behavior by addressing the underlying causes and providing proactive strategies.
  • Incident Report: This document is used to formally report serious incidents that may require further investigation or disciplinary action. It includes details of the incident, witnesses, and any immediate actions taken by staff.
  • Parent Communication Log: This log records all communications with parents or guardians regarding a student's behavior. It helps ensure that parents are kept informed and involved in their child's behavioral progress and interventions.
  • Referral to Counselor Form: When a student is referred to a school counselor for behavioral issues, this form documents the reasons for the referral and any relevant background information. It serves as a guide for the counselor to provide appropriate support.
  • Legal Documentation: In Maryland, having thorough legal documentation such as a Last Will is essential for ensuring that your intentions regarding asset distribution and guardianship are legally recognized and respected.
  • Disciplinary Action Record: This record tracks all disciplinary actions taken against a student, including suspensions, detentions, and other consequences. It helps maintain an accurate history of a student's behavioral issues and responses.

Using these documents in conjunction with the Louisiana School Behavior Report form creates a more complete picture of a student's behavior. This comprehensive approach not only aids in addressing current issues but also helps in preventing future incidents through effective communication and intervention strategies.