Incident Referral Forms Office of Family Services.

Incident Referral Forms

Office of Family Services

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Incident Referral Form

• The MPS Incident Referral Form was revised in the summer of 2009 as a result of the Positive Behavioral Interventions and Supports (PBIS) initiative.– Administrators, Principals, Teachers, Assistants,

Support Staff, and MTEA all had input on the revisions


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Incident Referral Form Revisions• The MPS Incident Referral Form was revised to do

the following:– Align with the Code of School/Classroom Conduct and

Discipline Chart in the Parent/Student Handbook on Rights, Responsibilities, and Discipline

– Save time using check boxes instead of writing everything out

– Align with the data entry process on the incident screen– Improve data collection for problem solving school-

wide/systems issues


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Types of Data From Referrals• The PBIS “Big 5” Reports:– Average Referrals per Day per Month– Referrals by Time– Referrals by Location– Referrals by Behavior– Referrals by Student

• These reports are used by the Tier 1/Universal Team to problem solve– When a report has “Unknown,” that means data was

not entered in that fieldOffice of Family Services

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Average Referrals per Day per Month


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Referrals by Time


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Referrals by Location


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Referrals by Behavior


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Referrals by Student


Student ID

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Incident Referral Form Revisions

• In addition to the revisions to the Incident Referral Form, the various offenses in eSIS were aligned to the Code of School/Classroom Conduct and Discipline Chart (pages 22-24 in the Parent/Student Handbook on Rights, Responsibilities and Discipline).– Previously there were over 140 types of offense

choices available on eSIS which made discipline data less useful for schools to problem solve with


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The following are simple guidelines all schools should utilize:

• No student should be removed from an instructional setting without an incident referral. Incident referrals that result in a student being removed from an instructional setting should be recorded on the Incident Screen in eSIS.


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Guidelines continued:

• No student should be suspended from school without an incident referral being recorded on the Incident Screen in eSIS.

• Incident referrals that are being written for a documentation purpose only and the student is not removed from the instructional setting should be recorded in eSIS Notes.


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• Bus referrals that are written by the bus driver that result in disciplinary action by an administrator should be transferred to an incident referral. The incident referral should be recorded on the incident screen in eSIS with the incident site identified as Transportation – Yellow. – These are incidents that result in the student being assigned a

detention, bus suspension, or suspension from school.

• Bus referrals written by a bus driver that do not result in disciplinary actions should be retained at the school for one year after the student leaves the district. – These are incidents that do not result in anything more than parent

contact or counseling by an administrator.Office of Family Services

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• Only one offense may be recorded in the incident screen in eSIS. If multiple offenses are checked on the incident referral, the administrator should select the most severe offense that is the main cause for disciplinary action. The additional offenses may be noted in the narrative.

• Multiple Administrative Actions may be recorded on the Incident Screen in eSIS, i.e., parent contact (14) and suspension (33).


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Blank Incident Referral Form: Front

It is important to complete all of the

fields on the Incident Referral Form.


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Incident Referral Form: Back

Directions for completing the

Incident Referral Form


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Sample Incident Referral Form

Possible Motivation:Why you think the student did what

they did. Use your professional

judgment. If you don’t know, select

Unclear/Don’t Know

Administrators may also complete the Possible Motivation field by asking the student: “Why did you do it?”

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Possible Motivation

• The Possible Motivation field is important when teams start implementing Tier 2 interventions. If the student is avoiding tasks/ activities, it may be for academic reasons not behavioral reasons. – The student does not understand how to

complete the equations, so he/she acts out instead to avoid the work


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T-Charts

• PBIS recommends the school staff members collaborate with the school administration for developing the T-Chart.

• The T-Chart identifies behaviors that are classroom managed and the behaviors that are office managed and must have an Incident Referral Form completed.


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Classroom Managed Office Managed(Minor) (Major)

• No Supplies• No

Homework• Talking• Gum• Tardy

• Fighting• Weapon• Illegal

Substances

Sample T-Chart


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Additional Information

• Keep in mind that Incident Referral Forms may be used as a legal document in some instances. – Statements should be professional at all times• i.e. legible, clear, good grammar and spelling

– Statements should simply relay the facts of the incident, not personal feelings or opinions.• i.e. “The student is a jerk!” is an example of

inappropriate information included on an Incident Referral Form


Incident Referral Forms Office of Family Services.

Documents

Transcript of Incident Referral Forms Office of Family Services.