Student Referral Form

FCPS Form 187-F06

Student Name Student Name First Last
Grade
Referring Driver or Assistant Referring Driver or Assistant First Last
Driver or Assistant FCPS Email Address
Incident Date Incident Date / MM / DD YYYY
Incident Time Incident Time : HH MM AM/PM
Location

Location Bus
Route Number
Choose School
Choose Transportation Manager
Administrators, please respond to email with action taken.
Motivation of Incident

Motivation of Incident Avoid Adult Avoid Peer Obtain Adult Attention Obtain Peer Attention Obtain Item Other
Others Involved (Choose One)

Others Involved (Choose One) Peers FCPS Staff Substitute Other None
Behavior Concerns
Minor Concerns

Minor Concerns Defiance of Authority Noncompliance with Bus Rules Continued Willful Disobedience Verbal Abuse Willful Damage of Property Inappropriate Physical Contact Profanity/Vulgarity Throwing Objects Other
Major Concerns (worthy of immediate referral)

Major Concerns (worthy of immediate referral) Fighting/Assault Throwing Harmful Objects False Identification/Refusal to Identify Theft/Extortion Intimidation/Harassment Use of Profanity/Abuse Directed at Driver/Assistant Possession/Use of Tobacco Possession/Use of Alcohol or Drugs Possession of Weapon or Explosive Device Possession of Look-a-likes Vandalism Discriminatory Practices Other
Action Taken by Driver Prior to Referral
Specific Action

Specific Action Verbal Warning Parent Contact Seat Assignment
Date of Verbal Warning Date of Verbal Warning / MM / DD YYYY
Date of Parent Contact Date of Parent Contact / MM / DD YYYY
Date of Seat Assignment Date of Seat Assignment / MM / DD YYYY
Other strategies or actions attempted:
Description of conduct/incident:

Student Referral Form

Student Referral Form

Administrators, please respond to email with action taken.

Behavior Concerns

Action Taken by Driver Prior to Referral