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Free Louisiana School Behavior Report Form

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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
(REVISED 9/15/2023)
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 ocials. 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/Sta: Teacher/Sta/Location:
Name of Principal: School:
Check One:
Regular Education 504 Special Education
Date of Incident: Time: Location:
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 Osite Program, 99 Other
INFRACTION/REASON CODES (Check all that apply)
01. Willful disobedience
02. Treats an authority with
disrespect
03. Makes an unfounded
charge against authority
04. Uses profane and/or
obscene language
05. Commits immoral or
vicious practices
06. Conduct or habits injurious
to his/her associates
07. Uses or possesses any
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
09. Uses or possesses
alcoholic beverages
10. Disturbs the school or
habitually violates any rule
11. Cuts, defaces, or injures
any part of public school
buildings/vandalism
12. Writes profane and/or
obscene language or
draws obscene pictures
13. Possesses weapon (s) as
defined in Section 921 of
Title 18 of the U.S. Code.
Use of code 13 requires
additional submission of
the Weapon Type code.
14. Possesses firearms (not
prohibited by federal
law), knives, or other
implements, which may
be used as weapons,
the careless use of which
might inflict harm or
injury (Excludes pocket
knives with a blade length
< 2 ½“ - refer to code 31).
15. Throws missiles liable to
injure others
16. Instigates or participates
in fights while under
school supervision
17. Violates trac and
safety regulations
18. Leaves school premises
or classroom without
permission
19. Is habitually tardy and/
or absent
20. Takes another’s property
or possessions without
permission
21. Commits any other
serious oense
30. Discharge or use of
weapon(s) prohibited by
federal law
31. Possesses pocket knife
or blade cutter with a
blade length < 2 ½”
33. Use of OTC medication
in a manner other than
prescribed or authorized
34. Possession of Body Armor
35. Bullying/Harrassment
(complete Bullying
Form and Bullying
Investigation Form)
36. Cyber Bullying (complete
Bullying Form and
Bullying Investigation
Form)
37. False Alarm/Bomb Threat
38. Forgery
39. Gambling
40. Public Indecency
41. Obscene behavior or
Possession of Obscene/
Pornographic Material
42. Unauthorized use of
Technology
43. Improper dress
44. Academic dishonesty
45. Trespassing Violation
46. Failure to Serve Assigned
Consequence
47. Misusing Internet/
Violates electronic/
technology policy
48. Sexual Harassment
49. False Report
50. Crime of Violence
(per R.S. 14:2B)
REMARKS/DESCRIPTION OF INCIDENT:
LOUISIANA DEPARTMENT OF EDUCATION SCHOOL BEHAVIOR REPORT
(REVISED 9/15/2023)
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 1
st
2
nd
3
rd
4
th
5
th
(circle one) or other cumulative behavioral referral(s). I have taken the following action(s):
011 Referred to Oce
012 Referred to Counselor
013 Referred to Social Worker
014 Referred to SBLC
018 Secondary Referral (PBIS)
019 Tertiary Referral (PBIS)
022 Therapeutic Removal
025 Intervention Room
080 Assigned Remedial Work
120 Student Conference
140 Student Reprimand
160 Loss of Privileges
030 Restorative Practices Implemented
173 Conference with Parents or Guardians
175 Conference with Principal
999 Other Action
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 1
st
2
nd
3
rd
4
th
5
th
(circle one) or other cumulative behavioral referral(s). I have taken the following action(s):
000 No Action – only use if no
reportable action was taken
001 Expulsion Recommendation
002 Suspension Out of School
from to
004 Suspension In School from to
006 Suspension Alternative Site
from to
012 Referred to Counselor
013 Referral to Social Worker
014 Referred to School Building Level
Committee (SBLC)
016 Court Referral Date:
017 Enforcement Referral (Arrest
Resulted Y N)
020 TOR (Time Out Room)
030 Restorative Practices Implemented
040 In School Detention from to
043 After School Detention from to
045 Weekend Detention from to
080 Assigned Remedial Work
120 Student Conference Date:
140 Student Reprimand
160 Loss of Privileges
173 Conference w/ Parents or
Guardians on:
175 Conference w/ Principal on:
180 Corporal Punishment (if checked,
complete “Corporal Punishment”
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 sta 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.
↓ 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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