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Free Louisiana School Behavior Report Form

The Louisiana School Behavior Report Form serves as a crucial tool for informing parents and guardians about behavior incidents occurring on school campuses or during school-related activities. This form outlines the details of the incident, the actions taken by school officials, and encourages communication between parents and students to address the behavior and prevent future occurrences. Parents are encouraged to fill out this form to ensure a collaborative approach to student behavior by clicking the button below.

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Free Louisiana School Behavior Report Form

Structure

The Louisiana School Behavior Report Form is a critical tool designed to communicate behavioral incidents that occur within school settings. This form serves multiple purposes, primarily aimed at informing parents or guardians about specific behavior incidents involving their children, which can happen in various locations such as classrooms, cafeterias, gymnasiums, or during school-related activities. It outlines the nature of the incident, the location, and the time it occurred, while also documenting any disciplinary actions taken by school officials. The form includes essential sections for identifying the student, teacher, and principal involved, as well as providing codes for different types of incidents, motivations, and influences that may have contributed to the behavior. It also captures whether serious bodily injury occurred and if medical treatment was required for either the perpetrator or the victim. Additionally, the report allows for a detailed description of the incident, actions taken by school staff, and recommendations for future behavior management. By using this form, schools aim to engage parents in discussions about their child's behavior, emphasizing the importance of collaboration to ensure the safety and well-being of all students.

Sample - Louisiana School Behavior Report Form

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.
03.	Makes an unfounded
	charge against authority
04.	Uses profane and/or	13.
	obscene language	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	15.
09.	Uses or possesses
	alcoholic beverages	16.
10.	Disturbs the school or	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
	18.	Leaves school premises	37.	False Alarm/Bomb Threat
Writes profane and/or		or classroom without	38.	Forgery
obscene language or		permission	38.	Forgery
obscene language or		permission	39.	Gambling
draws obscene pictures	19.	Is habitually tardy and/	39.	Gambling
	19.	Is habitually tardy and/	40.	Public Indecency
Possesses weapon (s) as		or absent	40.	Public Indecency
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.	21.	Commits any other	42.	Unauthorized use of
Possesses firearms (not		serious offense		Technology
Possesses firearms (not	30.	Discharge or use of	43.	Improper dress
prohibited by federal	30.	Discharge or use of	43.	Improper dress
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	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	46.	Failure to Serve Assigned
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			47.	Misusing Internet/
knives with a blade length				Violates electronic/
< 2 ½“ - refer to code 31).		in a manner other than		Violates electronic/
		in a manner other than		technology policy
		prescribed or authorized

Throws missiles liable to
Throws missiles liable to	34.	Possession of Body Armor	48.	Sexual Harassment
injure others	34.	Possession of Body Armor	48.	Sexual Harassment
injure others			49.	False Report
Instigates or participates	35.	Bullying/Harrassment	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

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

Resulted Y N)

173

Conference w/ Parents or

004

Suspension In School from

020

TOR (Time Out Room)

Guardians on:

006

Suspension Alternative Site

030

Restorative Practices Implemented

175

Conference w/ Principal on:

from

040

In School Detention from

180

Corporal Punishment (if checked,

012

Referred to Counselor

043

After School Detention from

complete “Corporal Punishment”

013

Referral to Social Worker

045

Weekend Detention from

Incidence Checklist)

999

Other Action(s):

Perpetrator: Serious Bodily Injury

Medical Treatment Y

N Victim: Serious Bodily Injury

Y N Medical Treatment

Contact Parent/Guardian? Y

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)

↓ Louisiana School Behavior Report File

Form Characteristics

Fact Name	Description
Governing Law	The Louisiana School Behavior Report form is governed by R.S. 17:416(A).
Purpose	This report informs parents or guardians about behavior incidents occurring on school grounds or during school-related activities.
Incident Locations	Incidents can occur in various locations, including classrooms, cafeterias, and during extracurricular activities.
Motivation Codes	The form includes motivation codes to help identify the reasons behind a student's behavior, such as avoiding adults or peers.
Serious Bodily Injury	The report requires checking if serious bodily injury occurred, both for the perpetrator and the victim.
Actions Taken	Teachers and school employees must document actions taken in response to the behavior, including referrals and disciplinary measures.
Parent Communication	Contacting parents or guardians is mandatory, with options for phone calls, letters, or conferences.
Documentation Requirements	Schools must keep a copy of the report in the pupil file and provide attachments related to the incident.

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