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MIDLOTHIAN INDEPENDENT SCHOOL DISTRICT ADMINISTRATIVE DISCIPLINARY REFERRAL FORM Student's Name ____________________________________________________________ ID# _______________ Grade: _______ Period: _______ Date: ____________________Time: __________ am/pm Teacher's Name __________________________________ Room: _____ Administrator: _____________________________________ Parent Name/Contact Info: ____________________________________ Violation Resulting in Referral (21) Student code of conduct violation not included (04) Marihuana or other controlled substance TEC 37.006 under TEC 37.002, 37.006, or 37.007 (a)(3), 37.007(b), and 37.007(a)(3) Cheating Fighting (33) Cigarette or Tobacco product defined in Health and Conduct Marks Destruction Disrespectful Disruptions Dress Code Excessive Tardies Other:

Notification Method Personal Contact Date/Time

Insubordination Profanity Skipping Class Skipping Detention Skpping Tutoring Theft of Property

Safety Code, Section 3.01, Chapter 161.252 Phone Conference (41) Fighting/Mutual combat (Exclude Penal 22.01) Date/Time (42) Truancy - Parent Contributing TEC §25.093(a) (43) Truancy - >3 Absences TEC §25.094 Letter (44) Truancy - >10 Absences TEC §25.094 This form (45) Truancy - Failure to Enroll TEC §25.085 37.006(a)(2) Certified Mail (50) Non-Illegal knife Code of Conduct, Less than/Equal 5.5" Other: (59) Serious misbehavior, as defined by TEC §37.007c, while expelled to or placed in a DAEP Pending *Violations resulting in Referral not listed from C164 of PEIMS Data Standards, code below. Parent Conference Location of Incident Prior Actions Taken by Teacher Hearing Violation Reported to TEA Bus Student/Teacher Conference ARD/MDR Cafeteria Teacher/Parent Phone Conference Reassignment Campus Grounds Teacher/Parent Conference Other: *Reference: C165 of Data Standards Classroom Teacher Referral to Counselor Special Education Commons/Mall Area Teacher Referral to Special Ed Gymnasium Teacher assigned Detention Ƒ Procedural Safeguards given Hallway Teacher/Student Contract Notice of Due Process Parking Lot Other: Emailed Assignment Restroom Mailed Days Assigned: Other: On Campus N/A In person signature Behavior Off Campus Location *File with referral Days Served: Where? Code Teacher Comments:

Administrator Comments:

Notice of Due Process Rights: At the conference, the administrator will inform the student of the misconduct for which he/she is charged & the consequences. The administrator will give the student an opportunity to give his/her version of the incident & the parent has the right to representation & appeal under board policy.

Actions Taken by Administrator (01) Expulsion w/out placement in another education setting as result formal hearing (02) Expulsion with placement in JJAEP as result of formal hearing (03) Expulsion with placement in an oncampus AEP as result of formal hearing (04) Expulsion with placement in offcampus DAEP as result of formal hearing (05) Out of School Suspension - limit of 3 days under TEC 37.005 (06) In School Suspension/CHOICES (07) Placement in on-campus or offcampus DAEP as result of conference and not a hearing (08) Continuation of other district's DAEP placement (09) Continuation of other district's expulsion order (10) Continuation of district's DAEP placement from prior school year (11) Continuation of district's expulsion order from prior school yr (12) Continuation of district's expulsion with placement JJAEP from prior school yr (13) Placement in JJAEP by court (14) Placement in DAEP by court (15) Continuation of other district's expulsion with placement to JJAEP (16) Truancy - Fine Assessed (17) Truancy - No Fine Assessed (25) Partial day Out of School Suspension (26)Partial day In School Suspension (27) Mandatory discipline action not taken as result of ARD committee (28) Mandatory discipline action not taken TEC §37.001(a)(4) Other: ASSIST D-Hall CP (Number ___ )/Witness: ________

Student Signature: ________________________________________________ Date: __________________ Parent Signature: ____________________________________________ Date: ________________ Distribution: White - Office, Green - Parent, Yellow - Teacher, Pink - Secretary, Gold - Student


Mhs referral