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Building Classroom Communities Referral Form

Behavior Goals on IEP?
Does this student currently have a 504 plan? *
Office Referrals 🛈
Violent Behavior without injury
Disruptive Behavior
Assault Staff Member without Injury
Assault Staff Member with Injury
Violent Behavior with Injury
Fighting without injury
Verbal assault
Possession of weapon
Technology violation
Fighting with injury
Attendance Hearings:
Has seclusion or restraint been required? *
Does the student have any current behavior plans? (BIP, iPlan, behavior contract) *

Have other interventions been tried? If so, please list.
Tier I
Tier II

Referred to:
 Plan of Action
Building Principal
Building PBIS Coach
Behavior Supports Program Coordinator
Special Education Behavior Coach

Students will remain on the Tier 2 list and discussion until the team has determined concerns have been resolved or student needs to move to Tier 3.


The Sioux City Community School District offers career and technical programs in the following areas: Business & Marketing, Family & Consumer Science, Health Science, and Industrial Arts, Technology, & PLTW.

The Sioux City Community School District is an equal opportunity/affirmative action employer and does not discriminate on the basis of race, creed, color, sex, sexual orientation, gender identity, genetic information (for employment), national origin, religion, age (for employment), disability, socioeconomic status (for programs), marital status (for programs), or veteran status (for employment) in its educational programs and its employment practices. The District is required by Title IX and 34 CFR Part 106 not to discriminate on the basis of sex in its programs, activities, or employment.

Inquiries or grievances under Section 504 and Title II of the Americans with Disabilities Act may be directed to Jen Gomez, Director of Student Services & Equity Education/Title IX Coordinator at 627 4th Street, Sioux City, IA 51101, (712) 279-6075, Inquiries about the application of Title IX and its regulations to the District may be referred to the Title IX Coordinator, the Assistant Secretary of the U.S. Department of Education, or both. Please see District Board policies 103 and 504.4 for additional information on available grievance procedures.