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BV Make a Difference Form
Student Name:
*
Teacher Name:
Date:
*
Year
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Time:
*
hour
1
2
3
4
5
6
7
8
9
10
11
12
:
minute
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
am
pm
Grade::
*
3
4
5
6
Location:
*
Playground
Cafeteria
Hallway
Classroom
Library
Bathroom
Gym/Art/Music
Bus
Other:
Minor Problem Behavior:
Disruption
Off Task
Disrespect
Physical Contact
Being Unsafe
Inappropriate Language or Behavior
Lying
Classroom Disruption
Horseplay
Teasing
Dress Code Violation
Other:
Major Problem Behavior:
Destruction of property
1st/2nd degree assault
Inappropriate Language/Behavior/Disrespect
Repeated profanity
Robbery
Fighting/physical aggression
Leave Campus
Repeated interference (defiant/disobedient)
Felonies
Detrimental Behavior
Dangerous Weapons
Drug Violation
3rd Degree Assault
Tobacco/Alcohol Violation
Other:
Possible Motivation:
Obtain Peer Attention
Obtain Adult Attention
Poor Impulse Control
Felt Threatened/mad/sad
Avoid Task or Activity
Don't Know
Other:
Action Taken:
None
Redirected
Loss of Privilege
Moved or Sent Out of Room
Turned Card/Lost Ticket
Parent Contact
Met With Counselor
In School Suspension
Out of School Suspension
Other:
Others Involved in The Incident:
None
Peers
Staff
Teacher
Substitute
Unknown
Other:
Other Comments:
Resolution: (Completed by the office):
Time in Office/teacher removal
Detention lunch/after school
In-school suspension
Counselor
Nurse
Loss of privilege
Parent contact
Out-of-School suspension
Behavior plan
Community agency
Conference with Student
Bus suspension
Refer to law enforcement
Student contract
Expulsion
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