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Building Classroom Communities Referral Form

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Gender
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Behavior Goals on IEP?
Does this student currently have a 504 plan? *
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Office Referrals 🛈
 ClassroomRecessOther
Violent Behavior without injury
Disruptive Behavior
Insubordination
Assault Staff Member without Injury
Stealing/Theft
Vandalism
Assault Staff Member with Injury
Attendance/truant
Profanity
Violent Behavior with Injury
Fighting without injury
Verbal assault
Disrespect
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.
 InterventionResults
Tier I
CHAMPS
Tier II

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

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.

NON-DISCRIMINATION STATEMENT

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. It is an unfair or discriminatory practice for any educational institution to 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.

Inquiries or grievances, including Section 504 grievances and grievances under Title II of the Americans with Disabilities Act, may be directed to Jen Gomez, Director of Student Services & Equity Education at 627 4th Street, Sioux City, IA 51101, (712) 279-6075, gomezj2@live.siouxcityschools.com. Please see District Board policies 103 and 504.4 for additional information on available grievance procedures.