Bellevue Elementary School Classroom Behavior Tracking Tool

Student: ____________________________ Staff Member: _____________________________

Minor Infractions are behaviors managed “on the spot.”

 Inappropriate comments/language – language that is meant to distract the educational process
 Non-compliance - refusal to follow teacher directions that do not disrupt student learning that can be
addressed with teacher interventions
 Interruption – behaviors that are managed through classroom interventions
 Minor defiance/disrespect – low level behaviors that do not disrupt student learning that can be
addressed with teacher interventions
 Horseplay – fooling around, inappropriate behaviors that disrupt the learning process
 Property Misuse – defacing personal or school property that is not permanent
 Inattentive/not participating – behaviors that disrupt the educational process of the individual that can
be addressed with teacher intervention
 Bullying- behavior that degrades or makes another feel uncomfortable or unsafe
 Electronic devices – should be confiscated and turned into the main office for parents to pick up
*After 5 minors, within one day, complete a major referral for administrative attention.*

1st Incident Date: Time:

Location Problem Behavior Environmental Factors Intervention Administered
(Check only 1) (Check only 1) (Check only 1)
o Classroom o Inappropriate o Adult request/directive o
o Special Area _________ comments/language o Whole group instruction _________________________________
o Hallway o Non-compliance o Independent work
o Bathroom o Interrupting/disruptive o Group work
o Cafeteria behavior o Transition
o Playground o Minor defiance/disrespect o Substitute teacher _________________________________
o Other _______________ o Horseplay o Changes in routine
o Property misuse o Teasing from peers
o Inattentive/not o Unstructured
participating situation/setting
o Bullying o Assembly
o Electronic devices o Other

2nd Incident Date: Time:

Location Problem Behavior Environmental Factors Intervention Administered
(Check only 1) (Check only 1) (Check only 1)
o Classroom o Inappropriate o Adult request/directive o
o Special Area _________ comments/language o Whole group instruction _________________________________
o Hallway o Non-compliance o Independent work
o Bathroom o Interrupting/disruptive o Group work
o Cafeteria behavior o Transition
o Playground o Minor defiance/disrespect o Substitute teacher _________________________________
o Other _______________ o Horseplay o Changes in routine
o Property misuse o Teasing from peers
o Inattentive/not o Unstructured
participating situation/setting
o Bullying o Assembly
 o Electronic devices o Other

3rd Incident Date: Time:

Location Problem Behavior Environmental Factors Intervention Administered
(Check only 1) (Check only 1) (Check only 1)
o Classroom o Inappropriate o Adult request/directive o
o Special Area _________ comments/language o Whole group instruction _________________________________
o Hallway o Non-compliance o Independent work
o Bathroom o Interrupting/disruptive o Group work
o Cafeteria behavior o Transition
o Playground o Minor defiance/disrespect o Substitute teacher _________________________________
o Other _______________ o Horseplay o Changes in routine
o Property misuse o Teasing from peers
o Inattentive/not o Unstructured
participating situation/setting
o Bullying o Assembly
o Electronic devices o Other

4th Incident Date: Time:

Location Problem Behavior Environmental Factors Intervention Administered
(Check only 1) (Check only 1) (Check only 1)
o Classroom o Inappropriate o Adult request/directive o
o Special Area _________ comments/language o Whole group instruction _________________________________
o Hallway o Non-compliance o Independent work
o Bathroom o Interrupting/disruptive o Group work
o Cafeteria behavior o Transition
o Playground o Minor defiance/disrespect o Substitute teacher _________________________________
o Other _______________ o Horseplay o Changes in routine
o Property misuse o Teasing from peers
o Inattentive/not o Unstructured
participating situation/setting
o Bullying o Assembly
o Electronic devices o Other

5th Incident Date: Time:

Location Problem Behavior Environmental Factors Intervention Administered
(Check only 1) (Check only 1) (Check only 1)
o Classroom o Inappropriate o Adult request/directive o
o Special Area _________ comments/language o Whole group instruction _________________________________
o Hallway o Non-compliance o Independent work
o Bathroom o Interrupting/disruptive o Group work
o Cafeteria behavior o Transition
o Playground o Minor defiance/disrespect o Substitute teacher _________________________________
o Other _______________ o Horseplay o Changes in routine
o Property misuse o Teasing from peers
o Inattentive/not o Unstructured o Parents must be contacted - (identify
participating situation/setting one – phone call, email, note home,
o Bullying o Assembly parent conference)
o Electronic devices o Other

*After the 5th Incident Complete Major Referral for Chronic Minor Infractions.*
*The office will make copies of this referral and mail one home to the parent or guardian.
 Teacher copy Parent copy Office copy
Bellevue Elementary School Major Offense - Office Referral Form

Student: ________________________ Referring Staff Member: __________________

Date: ___/___/___ Time: _________

Major Offenses are behaviors that require the immediate attention of an administrative staff member.

 Abusive language - abusive, profane, or derogatory language that is offensive

 Defiance/disrespect – hostile challenge of the authority of a staff member
 Disruptive behavior - behaviors that disrupt the classroom learning environment that have been
addressed with teacher interventions but were unsuccessful
 Bullying, harassment, threatening behavior – repeated behavior that degrades or makes another feel
unsafe
 Altercation, intentional physical contact, acts of physical violence – aggressive physical behavior
 Weapons – bringing and possessing a weapon at school
 Stealing (theft) – taking property that doesn’t belong to you with the intention of keeping it
 Possession of illegal substances – drugs, alcohol, tobacco
 Vandalism – permanent destruction of school or personal property
 Inappropriate sexual contact – touching or grabbing another student on a part of the body that is
regarded as private, such as buttocks, breast, genitalia
o removal of clothing to reveal underwear or private body parts

Location Problem Behavior Environmental Factors Intervention Administered

*factor that triggered the child’s behavior*
(Check only 1) (Check only 1) (Check only 1) o
o Classroom Major Offense o Adult request/directive _________________________________
o Special Area o Abusive language o Whole group instruction
_______ o Defiance/disrespect o Independent work
o Hallway o Bullying, harassment, o Group work
o Bathroom threatening behavior o Transition _________________________________
o Cafeteria o Interrupting/disruptive behavior o Substitute teacher
o Playground o Intentional physical contact o Changes in routine
o Weapons o Teasing from peers o Parent contact - (identify one – phone call,
o Stealing o Unstructured situation/setting email, note home, parent conference)
o Possession of illegal substances o Assembly
o Vandalism o Other o Referral to SIT (after 5 office visits)
o Inappropriate sexual contact
(Check only 1) Chronic Minor Infraction (Check only 1)
o Classroom (Attach Minor Infraction sheet) o Adult request/directive
o Special Area o Inappropriate o Whole group instruction
_______ comments/language o Independent work
o Hallway o Non-compliance o Group work
o Bathroom o Minor defiance/disrespect o Transition
o Cafeteria o Horseplay o Substitute teacher
o Playground o Property abuse o Changes in routine
o Inattentive/not participating o Teasing from peers
o Observed bullying o Unstructured situation/setting
o Electronic devices o Assembly
o Other
Provide a behaviorally specific description of the incident:

Referring Staff Signature: ________________________________________________

Check any services that this child receives: Others involved in the incident (provide first and
Special Education last name):
ELA Peer ________________________________
Math
AIS Staff/Teacher ________________________
Speech (IEP)
Counseling
Social Skills Group
OT Last parent/guardian contact: ___/___/___
PT Type of Communication:
Note Phone Call Meeting
Administrative Action Taken

Skill/Relationship Development: Other Administrative Action:

Recommend Problem Solving Meeting: Removal from class
Identify Academic, Environmental, Functional, and Behavior Assigned Time Out
Factors Assigned Detention: Lunch or After School
Targeted Skill Development (Coaching): In-school Suspension: partial day or *full day*
Scheduled Follow-Up Meeting: Out of school Suspension: partial day or *full day*
Parent Contact: Phone or Letter Home Referral to an outside agency:
Other: Other:

*REPORTABLE VADIR OFFENSE*

Principal/Assistant Principal’s Signature ______________________________________________________

*The office will make copies of this referral and mail one home to the parent or guardian.

Teacher copy Parent copy Office copy