Behavior Intervention Form

For a minor issue, a student must accrue 5 classroom demerits before submitting a Behavior Intervention Referral Form.

*Student's Name

*Grade Level

9th

10th

11th

12th

*Date

*Referring Teacher

Other's Involved in Incident

Possible Motivation

*Description of Incident: Observable Facts Only. Do not write opinions, hearsay, or interpretations.

*Have you had any contact with the Parents?

Did Student accrue 5 demerits before referral

Yes

Teacher Action before writeup

Administrator Action

Use capital letters when copying the code below.

Paul VI High School